Provider Demographics
NPI:1083960538
Name:PROVENZANO, LOUIS
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 65TH ST
Mailing Address - Street 2:#10P
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-4816
Mailing Address - Country:US
Mailing Address - Phone:718-753-6037
Mailing Address - Fax:
Practice Address - Street 1:25 CHAPEL ST
Practice Address - Street 2:SUITE 704
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1952
Practice Address - Country:US
Practice Address - Phone:718-522-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1289275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist