Provider Demographics
NPI:1790786473
Name:WILLIAMSON, MITCHELL TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:TODD
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:600 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7638
Mailing Address - Country:US
Mailing Address - Phone:770-995-0555
Mailing Address - Fax:770-995-0682
Practice Address - Street 1:600 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7638
Practice Address - Country:US
Practice Address - Phone:770-995-0555
Practice Address - Fax:770-995-0682
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0357892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000598012AMedicaid
GA13BDCDTMedicare PIN
GA000598012AMedicaid