Provider Demographics
NPI:1831162759
Name:PROVENCHER, MATTHEW T (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:T
Last Name:PROVENCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:181 W MEADOW DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81657-5242
Mailing Address - Country:US
Mailing Address - Phone:970-476-1100
Mailing Address - Fax:970-479-5835
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:SUITE 400
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-476-1100
Practice Address - Fax:970-479-5835
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA255099207XX0005X
CO56291207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine