Healthcare Provider Details

I. General information

NPI: 1245224864
Provider Name (Legal Business Name): DENNIS WORTHINGTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N MAYFAIR ROAD
WAUWATOSA WI
53226-4216
US

IV. Provider business mailing address

201 N MAYFAIR ROAD
WAUWATOSA WI
53226-4216
US

V. Phone/Fax

Practice location:
  • Phone: 414-259-7480
  • Fax: 414-259-7481
Mailing address:
  • Phone: 414-259-7480
  • Fax: 414-259-7481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number23370
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number23370
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: