Provider Demographics
NPI:1447343850
Name:WORNELL, DOUGLAS P (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:WORNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0140
Mailing Address - Country:US
Mailing Address - Phone:206-387-2469
Mailing Address - Fax:877-682-9319
Practice Address - Street 1:3309 56TH ST
Practice Address - Street 2:STE 106
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8580
Practice Address - Country:US
Practice Address - Phone:253-804-8259
Practice Address - Fax:253-804-8258
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000348672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWO9746OtherREGENCE RIDER NUMBER
WA1101419Medicaid
WA1101419Medicaid
WAAB00268Medicare ID - Type UnspecifiedMEDICARE NUMBER