Provider Demographics
NPI:1073607370
Name:BRAZOSPORT PROFESSIONAL EYE CLINIC INC
Entity Type:Organization
Organization Name:BRAZOSPORT PROFESSIONAL EYE CLINIC INC
Other - Org Name:MARK A PROVENZANO OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:979-299-3250
Mailing Address - Street 1:123 CIRCLE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5233
Mailing Address - Country:US
Mailing Address - Phone:979-299-3250
Mailing Address - Fax:979-299-1724
Practice Address - Street 1:123 CIRCLE WAY
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5233
Practice Address - Country:US
Practice Address - Phone:979-299-3250
Practice Address - Fax:979-299-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3979TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0195042Medicaid
TX80775QOtherBCBS OF TX
0328270001Medicare NSC
TX80775QOtherBCBS OF TX
TX00E79KMedicare PIN
TX8F9342Medicare PIN
TX00Z950Medicare PIN