Healthcare Provider Details

I. General information

NPI: 1588805303
Provider Name (Legal Business Name): MIKAELA LYNN CHILSTROM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 DEKALB MEDICAL PKWY
LITHONIA GA
30058-4996
US

IV. Provider business mailing address

2100 POWELL ST STE 400
EMERYVILLE CA
94608-1872
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-5207
  • Fax:
Mailing address:
  • Phone: 862-250-2688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number64349
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA122245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: