Provider Demographics
NPI:1588246102
Name:THOMAS, BENJAMIN JACOB (DO)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JACOB
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 1:131 COVENTRY ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1548
Mailing Address - Country:US
Mailing Address - Phone:860-714-3690
Mailing Address - Fax:860-714-8541
Practice Address - Street 1:131 COVENTRY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1548
Practice Address - Country:US
Practice Address - Phone:860-714-3690
Practice Address - Fax:860-714-8541
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RILP05324207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program