MEDICARE: DR. ROBERT PROVENZANO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	M-11205	ID
2	207RN0300X	Nephrology Physician	4301047354	MI
3	207RN0300X	Nephrology Physician	54729	AZ
4	207RN0300X	Nephrology Physician	2017-00405	NC
5	207RN0300X	Nephrology Physician	40429	SC
6	207RN0300X	Nephrology Physician	MD463387	PA
7	207RN0300X	Nephrology Physician	ME118456	FL
8	207RN0300X	Nephrology Physician	48234	CO
9	207RN0300X	Nephrology Physician	MD0000053388	TN
10	207RN0300X	Nephrology Physician	MD170613	OR
11	207RN0300X	Nephrology Physician	RP047354	MI

General Provider Information

NPI Number	:	1972505584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT PROVENZANO MD

Provider Business Mailing Address
First Line	:	1840 E RAY RD
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85225-8720
Country	:	US
Telephone Number	:	855-397-0197
Fax Number	:	800-272-6512

Provider Business Practice Location Address
First Line	:	1547 NE 40TH AVE STE B
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1862
Country	:	US
Telephone Number	:	855-397-0197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	11/26/2019

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Directions to “ DR. ROBERT PROVENZANO MD” Practice Location

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