Provider Demographics
NPI:1396941449
Name:WORTHAM, ANGELA H (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:H
Last Name:WORTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-226-0340
Practice Address - Fax:901-226-0349
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS222412085R0001X, 2085R0001X
TN488422085R0001X, 2085R0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4F719DX68OtherANGELA WORTHAM MEDICARE PTAN EFFECTIVE 05/19/2012
LA2113119Medicaid
LA203417OtherLOUISIANA MEDICAL LICENSE
LA4F719OtherMEDICARE
LA5DX68OtherONCOLOGICS LLC GROUP MEDICARE PTAN EFFECTIVE 05/19/2012