Individual
THEODORE NICHOLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
705 DIXIE ST, CARROLLTON, GA 30117-3818
(770) 836-9666
Mailing address
2346 BOWWOOD CT, VILLA RICA, GA 30180-9733
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
029920
GA
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
029920
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000390288B
—
GA
Enumeration date
04/27/2006
Last updated
04/28/2010
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