Provider Demographics
NPI:1053371344
Name:WORMUTH, DAVID WILSON (MD, MPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WILSON
Last Name:WORMUTH
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 BRITTONFIELD PKWY STE 700
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9249
Mailing Address - Country:US
Mailing Address - Phone:315-234-7860
Mailing Address - Fax:315-634-5170
Practice Address - Street 1:5008 BRITTONFIELD PKWY STE 700
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9249
Practice Address - Country:US
Practice Address - Phone:315-234-7860
Practice Address - Fax:315-634-5170
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218591208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02091129Medicaid
NYP00446825OtherRAILROAD MEDICARE
NYH27241Medicare UPIN
NYRB6668Medicare PIN