Provider Demographics
NPI:1831158252
Name:WORTH, KEVIN R (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:WORTH
Suffix:
Gender:M
Credentials:OD
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 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:214 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072
Practice Address - Country:US
Practice Address - Phone:765-675-3937
Practice Address - Fax:765-675-3938
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003353A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200522840Medicaid
IN811310HMedicare PIN
IN160450TMedicare PIN
IN200522840Medicaid
INP00627233Medicare PIN
IN367160IMedicare PIN
V05803Medicare UPIN
IN222860CMedicare PIN