Provider Demographics
NPI:1063461846
Name:ANTONIOS, DAWIT TEKLEMARIAM (MD)
Entity Type:Individual
Prefix:
First Name:DAWIT
Middle Name:TEKLEMARIAM
Last Name:ANTONIOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1170
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1170
Mailing Address - Country:US
Mailing Address - Phone:470-325-0159
Mailing Address - Fax:470-325-0191
Practice Address - Street 1:2801 DEKALB MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4996
Practice Address - Country:US
Practice Address - Phone:404-501-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055388207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA580618709FMedicaid
GA580618709FMedicaid
GAI19634Medicare UPIN