Basic Information
| Provider Information | |||||||||
| NPI: | 1225031594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WORDEN | ||||||||
| FirstName: | DONZA | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 506 | ||||||||
| Address2: | |||||||||
| City: | PICKFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066472217 | ||||||||
| FaxNumber: | 9066472228 | ||||||||
| Practice Location | |||||||||
| Address1: | 33896 S TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | DRUMMOND ISLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066472217 | ||||||||
| FaxNumber: | 9066472228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301057132 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3428660 | 05 | MI | MEDICAID |