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General NPI Number Information
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NPI Number | 1245267624
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Entity Type | Individual
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Provider Name | DAVID GERARD PROVAZNIK DO
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Gender | Male
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Dates
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Enumeration Date | 06/28/2006
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Last Update Date | 02/12/2014
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Provider Practice Location Address
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Address Line | 11826 GALLIA PIKE SUITE A
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City | WHEELERSBURG
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State | OH
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Zip | 45694-9119
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Country | US
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Telephone | 740-574-4526
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Fax | 740-574-2895
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Provider Business Mailing Address
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Address Line | PO BOX 2379
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City | ASHLAND
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State | KY
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Zip | 41105-2379
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Country | US
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Telephone | 740-574-4526
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Fax | 740-574-2895
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34005337
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License Number State | OH
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