Provider Demographics
NPI:1235718529
Name:THEISEN, BENJAMIN WATERS (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WATERS
Last Name:THEISEN
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 1:1900 MCNATT DR APT 14
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-9024
Mailing Address - Country:US
Mailing Address - Phone:517-294-9944
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS WAY # 512-19A
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program