Provider Demographics
NPI:1316960115
Name:THOMAS, BENNY EARL (DO)
Entity type:Individual
Prefix:MR
First Name:BENNY
Middle Name:EARL
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4503
Mailing Address - Street 2:215 NORTH ST.
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583
Mailing Address - Country:US
Mailing Address - Phone:573-774-6279
Mailing Address - Fax:573-774-5626
Practice Address - Street 1:215 NORTH ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583
Practice Address - Country:US
Practice Address - Phone:573-774-6279
Practice Address - Fax:573-774-5626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34548207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240424606Medicaid
MOD41685Medicare UPIN
MO000003621Medicare ID - Type Unspecified