Provider Demographics
NPI:1326029125
Name:EDWARDS, THOMAS ELLIOT JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ELLIOT
Last Name:EDWARDS
Suffix:JR
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 1:2799 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2531
Mailing Address - Country:US
Mailing Address - Phone:678-534-0200
Mailing Address - Fax:678-534-0201
Practice Address - Street 1:2799 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2531
Practice Address - Country:US
Practice Address - Phone:678-534-0200
Practice Address - Fax:678-534-0201
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038743174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000613082DMedicaid
GAF83922Medicare UPIN
GA000613082DMedicaid