Provider Demographics
NPI:1063486843
Name:SISTRUNK, THOMAS LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEWIS
Last Name:SISTRUNK
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 1:119 MAPLE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3230
Mailing Address - Country:US
Mailing Address - Phone:770-831-0751
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-836-9660
Practice Address - Fax:770-812-5028
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0194242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000229567BMedicaid
GA028143OtherBLUE CROSS BLUE SHIELD
GAE87640Medicare UPIN
GA30CDBCBMedicare ID - Type Unspecified