Provider Demographics
NPI:1881125367
Name:WORDEN, IAN (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:WORDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 PENBERTON DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-3020
Mailing Address - Country:US
Mailing Address - Phone:916-367-9117
Mailing Address - Fax:
Practice Address - Street 1:5301 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.152132207L00000X
390200000X
MI4301504789207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088846Medicaid