Provider Demographics
NPI:1689866725
Name:DE MIRANDA, THOMAS BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BENJAMIN
Last Name:DE MIRANDA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3790 N BELLAFONT BLVD
Mailing Address - Street 2:STE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5481
Mailing Address - Country:US
Mailing Address - Phone:479-439-0777
Mailing Address - Fax:888-815-1613
Practice Address - Street 1:3790 N BELLAFONT BLVD
Practice Address - Street 2:STE 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5481
Practice Address - Country:US
Practice Address - Phone:479-439-0777
Practice Address - Fax:888-815-1613
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2022-05-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK27166207Q00000X
ARE-6411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5H745OtherAR BC/BS
AR182726001Medicaid
AR5AD25Medicare PIN
AR5AD25F276Medicare PIN