Healthcare Provider Details

I. General information

NPI: 1003822875
Provider Name (Legal Business Name): MARK THOMAS WORTHINGTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-1612
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-243-3090
  • Fax: 434-244-9445
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101054161
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD40278
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number43526
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101054161
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: