Provider Demographics
NPI:1447217906
Name:PANTINO, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PANTINO
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 1:165 FLOWING SPRING TRL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1867
Mailing Address - Country:US
Mailing Address - Phone:770-642-0393
Mailing Address - Fax:
Practice Address - Street 1:3795 MANSELL RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-8247
Practice Address - Country:US
Practice Address - Phone:404-785-8540
Practice Address - Fax:404-785-8574
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038904174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000616844Medicaid
00616844JMedicare ID - Type Unspecified
GA000616844Medicaid