Provider Demographics
NPI:1336401256
Name:PROENZA, MANUEL A (DO)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:PROENZA
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:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:
Practice Address - Street 1:1101 26TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5161
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1964208000000X
MT142414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV111351Medicare PIN