Provider Demographics
NPI:1639281678
Name:THOMSON PODIATRY ASSOCIATES, PC
Entity Type:Organization
Organization Name:THOMSON PODIATRY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-597-0102
Mailing Address - Street 1:1043 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-7318
Mailing Address - Country:US
Mailing Address - Phone:706-597-0102
Mailing Address - Fax:706-597-1998
Practice Address - Street 1:1043 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7318
Practice Address - Country:US
Practice Address - Phone:706-597-0102
Practice Address - Fax:706-597-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000713213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000701511EMedicaid
GAPOD001025OtherLICENSE #
GA733822071AMedicaid
GAPOD000713OtherLICENSE #
GA000971517AMedicaid
GA000971517AMedicaid
GABN2529850OtherDEA
GABM4514558OtherDEA
GAPOD000713OtherLICENSE #
GABN2529850OtherDEA
GAU08969Medicare UPIN
GAPOD001025OtherLICENSE #
GA000971517AMedicaid