Provider Demographics
NPI:1114367711
Name:THOMAS, TRISTAN KEON (MD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:KEON
Last Name:THOMAS
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 1:1700 HOSPITAL SOUTH DR STE 202
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8116
Mailing Address - Country:US
Mailing Address - Phone:770-944-7818
Mailing Address - Fax:
Practice Address - Street 1:1700 HOSPITAL SOUTH DR STE 202
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-944-7818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83784208600000X
SCLL36019208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery