Healthcare Provider Details

I. General information

NPI: 1316960115
Provider Name (Legal Business Name): BENNY EARL THOMAS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 NORTH ST
WAYNESVILLE MO
65583
US

IV. Provider business mailing address

PO BOX 4503 215 NORTH ST.
WAYNESVILLE MO
65583
US

V. Phone/Fax

Practice location:
  • Phone: 573-774-6279
  • Fax: 573-774-5626
Mailing address:
  • Phone: 573-774-6279
  • Fax: 573-774-5626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34548
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number34548
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: