Healthcare Provider Details

I. General information

NPI: 1326098120
Provider Name (Legal Business Name): DAVID E. PROVENCHER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SOUTHERN OAK DRIVE
PLANT CITY FL
33563
US

IV. Provider business mailing address

PO BOX 2156
PLANT CITY FL
33564-2156
US

V. Phone/Fax

Practice location:
  • Phone: 813-752-8595
  • Fax: 813-752-8088
Mailing address:
  • Phone: 813-486-2085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberME81615
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberME81615
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: