Individual
MATTHEW J PROVENZANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1225 E COOLSPRING AVE STE 300, MICHIGAN CITY, IN 46360-6312
(219) 878-5032
(219) 861-8151
Mailing address
PO BOX 781076, DETROIT, MI 48278-1076
(317) 528-4800
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
01072216A
IN
207Y00000X
Otolaryngology Physician
36490
IA
207YP0228X
Pediatric Otolaryngology Physician
Primary
01072216A
IN
207YP0228X
Pediatric Otolaryngology Physician
57.019215
OH
Other
Enumeration date
05/22/2007
Last updated
08/24/2023
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