Provider Demographics
NPI:1235297599
Name:IWANICKI, TODD W (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:W
Last Name:IWANICKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:WILLIAM
Other - Last Name:IWANICKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7000 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:BLDG 16 S 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-393-1880
Mailing Address - Fax:770-393-1885
Practice Address - Street 1:7000 PEACHTREE DUNWOODY RD
Practice Address - Street 2:BLDG 16 S 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:770-393-1880
Practice Address - Fax:770-393-1885
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0395982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABI6144795OtherDEA
G27317Medicare UPIN