Healthcare Provider Details

I. General information

NPI: 1336401256
Provider Name (Legal Business Name): MANUEL A PROENZA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 26TH ST S
GREAT FALLS MT
59405-5161
US

IV. Provider business mailing address

PO BOX 6010
GREAT FALLS MT
59406-6010
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-8888
  • Fax: 406-731-8318
Mailing address:
  • Phone: 406-731-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO1964
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number142414
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: