MEDICARE: JOSEPH JOHNNY PROVENZANO JR. DO

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	207Q00000X	Family Medicine Physician	20A5427	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215993738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH JOHNNY PROVENZANO JR. DO

Provider Business Mailing Address
First Line	:	10470 OLD PLACERVILLE RD STE 100
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95827-2539
Country	:	US
Telephone Number	:	800-470-0071
Fax Number	:

Provider Business Practice Location Address
First Line	:	3612 DALE RD
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95356-0500
Country	:	US
Telephone Number	:	209-522-0146
Fax Number	:

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	06/11/2019

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