Healthcare Provider Details

I. General information

NPI: 1679580492
Provider Name (Legal Business Name): REX EMERSON WORTHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S 1ST W
PRESTON ID
83263-1244
US

IV. Provider business mailing address

8 S 1ST W
PRESTON ID
83263-1244
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-0852
  • Fax: 208-852-0568
Mailing address:
  • Phone: 208-852-0852
  • Fax: 208-852-0568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-7249
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: