Provider Demographics
NPI:1184794745
Name:PROVENCHER, MARC A (OD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:PROVENCHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 S TIMBERLINE RD UNIT 120
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6023
Mailing Address - Country:US
Mailing Address - Phone:970-282-8888
Mailing Address - Fax:970-282-8484
Practice Address - Street 1:4050 S TIMBERLINE RD UNIT 120
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-6023
Practice Address - Country:US
Practice Address - Phone:970-282-8888
Practice Address - Fax:970-282-8484
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY209T152WC0802X
CO2025152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659005387OtherTYPE 2 NPI
COC49253Medicare ID - Type Unspecified