Healthcare Provider Details

I. General information

NPI: 1174517403
Provider Name (Legal Business Name): WILLIAM J PROVANCE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 08/03/2007

III. Provider practice location address

681 GOODLETTE RD N STE 130
NAPLES FL
34102-5458
US

IV. Provider business mailing address

3434 HANCOCK BRIDGE PKWY STE 301
NORTH FORT MYERS FL
33903-7094
US

V. Phone/Fax

Practice location:
  • Phone: 239-643-9767
  • Fax: 239-649-5878
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS12406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: