Provider Demographics
NPI:1457301673
Name:GAUTHIER, THERESA W (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:W
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:WANZOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2015 UPPERGATE DR
Mailing Address - Street 2:3RD FL
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322
Mailing Address - Country:US
Mailing Address - Phone:404-727-1471
Mailing Address - Fax:404-727-3236
Practice Address - Street 1:2015 UPPERGATE DR
Practice Address - Street 2:3RD FL
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-727-1471
Practice Address - Fax:404-727-3236
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0400742080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G05389Medicare UPIN