Provider Demographics
NPI:1316949365
Name:THRELKELD, ANISA B (MD)
Entity type:Individual
Prefix:
First Name:ANISA
Middle Name:B
Last Name:THRELKELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FY RD NE
Mailing Address - Street 2:SUITE 550
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1626
Mailing Address - Country:US
Mailing Address - Phone:404-631-6440
Mailing Address - Fax:404-631-6332
Practice Address - Street 1:980 JOHNSON FY RD NE
Practice Address - Street 2:SUITE 550
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1626
Practice Address - Country:US
Practice Address - Phone:404-631-6440
Practice Address - Fax:404-631-6332
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38988207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000619077Medicaid
GA000619077Medicaid
GA18BDFLZMedicare ID - Type Unspecified