Provider Demographics
NPI:1427117795
Name:WORTMAN, ROBERT A (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:WORTMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1420 WALNUT ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4017
Mailing Address - Country:US
Mailing Address - Phone:215-735-6300
Mailing Address - Fax:215-735-2244
Practice Address - Street 1:1420 WALNUT ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4017
Practice Address - Country:US
Practice Address - Phone:215-735-6300
Practice Address - Fax:215-735-2244
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001041152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA164905Medicare PIN
PAT29833Medicare UPIN