Healthcare Provider Details

I. General information

NPI: 1649929589
Provider Name (Legal Business Name): LINDSEY ANNE THEODORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2022
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 KLONDIKE RD SW STE 205
CONYERS GA
30094-5173
US

IV. Provider business mailing address

1506 KLONDIKE RD SW STE 205
CONYERS GA
30094-5173
US

V. Phone/Fax

Practice location:
  • Phone: 678-750-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number104471
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: