Provider Demographics
NPI:1790891448
Name:JEFFERSON, THOMAS T (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
Last Name:JEFFERSON
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:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1841
Mailing Address - Country:US
Mailing Address - Phone:479-437-3449
Mailing Address - Fax:479-243-0285
Practice Address - Street 1:1100 N UNIVERSITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-6360
Practice Address - Country:US
Practice Address - Phone:888-710-8220
Practice Address - Fax:866-573-0761
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4604208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104422001Medicaid
AR104422001Medicaid
ARC4604OtherSTATE LICENSE
AR489896YJG2Medicare UPIN
AR104422001Medicaid