Healthcare Provider Details

I. General information

NPI: 1356701189
Provider Name (Legal Business Name): HEATHER RAE WORTHAM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1321
  • Fax: 863-284-1730
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5315076011
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberOS18693
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: