Provider Demographics
NPI:1962456905
Name:PROVENZANO, RICHARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:PROVENZANO
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 1:322 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2225
Mailing Address - Country:US
Mailing Address - Phone:802-447-8700
Mailing Address - Fax:802-447-1500
Practice Address - Street 1:322 DEWEY ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2225
Practice Address - Country:US
Practice Address - Phone:802-447-8700
Practice Address - Fax:802-447-1500
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45884207W00000X
VT042-0006501207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTI19054OtherMABS
NY00461192Medicaid
VTVT5144OtherVTBS
MA000000024109OtherBMC
VT10001651OtherCDPHP
VT15622Other15622
MA15622OtherHNE
VT17155OtherMVP
VT000000024110OtherBMC
MA110000678AMedicaid
MA10001651OtherCDPHP
MAI19054OtherMABS
VT0005144Medicaid
MA17155OtherMVP
VT15622Other15622
VTA55788Medicare UPIN
VT0005144Medicaid
MA110000678AMedicaid
VTVT5144OtherVTBS
MAI19054OtherMABS