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:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 MARKET TRCE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8694
Mailing Address - Country:US
Mailing Address - Phone:479-434-3600
Mailing Address - Fax:833-992-0797
Practice Address - Street 1:2707 MARKET TRCE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8694
Practice Address - Country:US
Practice Address - Phone:479-434-3600
Practice Address - Fax:833-992-0797
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6411208VP0014X, 207Q00000X
OK27166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5H745OtherAR BC/BS
AR182726001Medicaid
AR5AD25Medicare PIN
AR5AD25F276Medicare PIN