Healthcare Provider Details

I. General information

NPI: 1558583492
Provider Name (Legal Business Name): THEODORE WILLIAMS SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EDGEWOOD AVENUE N.E. SUITE 1228
ATLANTA GA
30303-3068
US

IV. Provider business mailing address

3013 HAMPTON CLUB WAY
LITHONIA GA
30038-5102
US

V. Phone/Fax

Practice location:
  • Phone: 770-319-1595
  • Fax: 770-234-3934
Mailing address:
  • Phone: 770-319-1595
  • Fax: 770-234-3934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number032303
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number032303
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: