Individual
MARK EDWARD VAN WORMER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
314 N 3RD AVE, CLAYTON, NM 88415-3302
(575) 374-8313
(575) 374-2064
Mailing address
314 N 3RD AVE, CLAYTON, NM 88415-3302
(575) 374-8313
(575) 374-2064
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
81333
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05645
—
NM
01
—
060000475
RAILROAD MEDICARE
—
Enumeration date
08/10/2005
Last updated
07/15/2009
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