Basic Information
Provider Information | |||||||||
NPI: | 1396078200 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMASSON | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | GOLDEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 370 | ||||||||
Address2: |   | ||||||||
City: | FORTSON | ||||||||
State: | GA | ||||||||
PostalCode: | 318080370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063246661 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6775 CHOPRA TER STE 300 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328275811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073400263 | ||||||||
FaxNumber: | 8442514517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2009 | ||||||||
LastUpdateDate: | 06/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | P9266 | TX | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | OS13167 | FL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 5680 | OK | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 22603 | NH | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | OS13167 | FL | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.