Healthcare Provider Details

I. General information

NPI: 1023690443
Provider Name (Legal Business Name): TRISTAN VAN VOORHIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

IV. Provider business mailing address

878 BRIARCLIFF RD NE APT A1
ATLANTA GA
30306-4084
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1440
  • Fax:
Mailing address:
  • Phone: 315-447-8045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number100048
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: