Provider Demographics
NPI:1134143910
Name:HALTOM, THOMAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:HALTOM
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 1:1401 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6495
Mailing Address - Country:US
Mailing Address - Phone:770-971-5494
Mailing Address - Fax:770-971-0467
Practice Address - Street 1:1401 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 390
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6495
Practice Address - Country:US
Practice Address - Phone:770-971-5494
Practice Address - Fax:770-971-0467
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028779207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52572062014OtherBLUECROSS BLUESHIELD
GAD29561Medicare UPIN
GA93BBJQQMedicare ID - Type Unspecified