Provider Demographics
NPI:1871559542
Name:WORTHINGTON, JOHN WALTER (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTER
Last Name:WORTHINGTON
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD
Practice Address - Street 2:STE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5608
Practice Address - Country:US
Practice Address - Phone:864-455-6900
Practice Address - Fax:864-255-5619
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9707207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC097077Medicaid
SCAA77267951Medicare PIN
SCB916043640Medicare PIN
SCAA40162199Medicare PIN
SCAA40167951Medicare PIN
SC097077Medicaid