Provider Demographics
NPI:1164740627
Name:PROHASKA, MATTHEW GREGORY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:GREGORY
Last Name:PROHASKA
Suffix:JR
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 905
Mailing Address - Street 2:NVRH ORTHOPAEDICS
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-8141
Mailing Address - Fax:
Practice Address - Street 1:1315 HOSPITAL DR
Practice Address - Street 2:NVRH ORTHOPAEDICS
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9210
Practice Address - Country:US
Practice Address - Phone:802-748-8141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-08
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042-0013063207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3100897Medicaid
VT1024556Medicaid
NH3100897Medicaid