Provider Demographics
NPI:1326098120
Name:PROVENCHER, DAVID E JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
Last Name:PROVENCHER
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 2156
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33564-2156
Mailing Address - Country:US
Mailing Address - Phone:813-486-2085
Mailing Address - Fax:
Practice Address - Street 1:106 SOUTHERN OAK DRIVE
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563
Practice Address - Country:US
Practice Address - Phone:813-752-8595
Practice Address - Fax:813-752-8088
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME816152080P0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262145201Medicaid
FLH46274Medicare UPIN
FL262145201Medicaid