Provider Demographics
NPI:1558583492
Name:SMITH, THEODORE WILLIAMS (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:WILLIAMS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3013 HAMPTON CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-5102
Mailing Address - Country:US
Mailing Address - Phone:770-319-1595
Mailing Address - Fax:770-234-3934
Practice Address - Street 1:100 EDGEWOOD AVENUE N.E.
Practice Address - Street 2:SUITE 1228
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3068
Practice Address - Country:US
Practice Address - Phone:770-319-1595
Practice Address - Fax:770-234-3934
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0323032084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAFO8972Medicare UPIN