=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922095777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN FORDYCE WORTH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2005
-----------------------------------------------------
Last Update Date | 03/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7444 W ALASKA DR STE 250
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80226-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-592-7284
-----------------------------------------------------
Fax | 303-892-0601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11600 W 2ND PL
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-592-7284
-----------------------------------------------------
Fax | 303-892-0601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 40347
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------