Provider Demographics
NPI:1356374987
Name:WORTH, VICTOR RYAN (DO)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:RYAN
Last Name:WORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-477-3317
Mailing Address - Fax:435-477-9805
Practice Address - Street 1:15 EAST 400 NORTH
Practice Address - Street 2:
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761-0000
Practice Address - Country:US
Practice Address - Phone:435-477-3317
Practice Address - Fax:435-477-9805
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1331-05207Q00000X
UT9691680-8204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90658761Medicaid
NM348518901Medicare ID - Type Unspecified
NM90658761Medicaid
NM850438294Medicare PIN