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General NPI Number Information
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NPI Number | 1316283260
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Entity Type | Organization
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Legal Business Name | J M PROVENZANO MD PA
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Dates
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Enumeration Date | 12/21/2012
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Last Update Date | 12/21/2012
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Provider Practice Location Address
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Address Line | 906 S FEDERAL HWY STE A
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City | BOYNTON BEACH
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State | FL
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Zip | 33435-5671
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Country | US
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Telephone | 561-736-7330
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Fax | 561-736-7388
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Provider Business Mailing Address
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Address Line | 906 S FEDERAL HWY STE A
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City | BOYNTON BEACH
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State | FL
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Zip | 33435-5671
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Country | US
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Telephone | 561-736-7330
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Fax | 561-736-7388
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOSEPH MICHAEL PROVENZANO
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Credential | M.D.
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Telephone | 561-736-7330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 51311
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License Number State | FL
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