Healthcare Provider Details

I. General information

NPI: 1275590051
Provider Name (Legal Business Name): THEODORE NICHOLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 DIXIE ST
CARROLLTON GA
30117-3818
US

IV. Provider business mailing address

2346 BOWWOOD CT
VILLA RICA GA
30180-9733
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-9666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number029920
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number029920
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000390288B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: