Provider Demographics
NPI:1730299702
Name:NIMMO, BENJAMIN T (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:T
Last Name:NIMMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 FINANCIAL CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3715
Mailing Address - Country:US
Mailing Address - Phone:501-223-3322
Mailing Address - Fax:
Practice Address - Street 1:11501 FINANCIAL CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3715
Practice Address - Country:US
Practice Address - Phone:501-223-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-31772084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146296001Medicaid
AR71-0401764OtherCORPHEALTH
AR00000H56357OtherUNITY MANAGED MENTAL HLTH
AR05070022703OtherQUAL-CHOICE
AR5M158OtherBLUE CROSS & BLUE SHIELD
AR5M158OtherBLUE CROSS & BLUE SHIELD