Healthcare Provider Details

I. General information

NPI: 1437357423
Provider Name (Legal Business Name): TIAN XIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N BROAD ST
WINDER GA
30680-2153
US

IV. Provider business mailing address

5330 NORTHWATER WAY
DULUTH GA
30097-2485
US

V. Phone/Fax

Practice location:
  • Phone: 770-868-1144
  • Fax: 770-868-1276
Mailing address:
  • Phone: 770-840-8581
  • Fax: 770-840-0641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3045
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number116019066
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: