Provider Demographics
NPI:1669402152
Name:PROVENCHER, ROBERT A (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:PROVENCHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 KINGS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020
Mailing Address - Country:US
Mailing Address - Phone:856-423-7000
Mailing Address - Fax:
Practice Address - Street 1:296 KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:CLARKSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08020
Practice Address - Country:US
Practice Address - Phone:856-423-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04853900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E06168Medicare UPIN
165397Medicare ID - Type Unspecified