Provider Demographics
NPI:1780256461
Name:WORTHINGTON, DOUGLAS ANDRE
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ANDRE
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 HAYDEN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-3255
Mailing Address - Country:US
Mailing Address - Phone:614-586-5917
Mailing Address - Fax:
Practice Address - Street 1:120 W 2ND ST STE 425
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1623
Practice Address - Country:US
Practice Address - Phone:937-979-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator