Healthcare Provider Details

I. General information

NPI: 1720261456
Provider Name (Legal Business Name): MARK PROVENZANO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL RD
HOUSTON TX
77024-2804
US

IV. Provider business mailing address

PO BOX 3961
HOUSTON TX
77253-3961
US

V. Phone/Fax

Practice location:
  • Phone: 713-464-0077
  • Fax: 713-464-9582
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG3705
License Number StateTX

VIII. Authorized Official

Name: KRISTY MCDOWELL
Title or Position: BILLING/INSURANCE
Credential:
Phone: 713-464-0077