| Doctor Name: | MARK EDWARD VAN WORMER |
| NPI Number: | 1013919034 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 81333 |
| Business Practice Address: | 314 N 3rd Ave Clayton, NM - 884153302 |
| Business Phone Number: | 5753748313 |
| Business Fax Number: | 5753742064 |
| Mailing Address: | 314 N 3rd Ave, CLAYTON |
| State: | NM |
| Postal Code: | 884153302 |
| Phone Number: | 5753748313 |
| Fax Number: | 5753742064 |
| NPI Enumeration Date: | 08/10/2005 |
| NPI Last Update Date: | 07/15/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 81333 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |