Provider Demographics
NPI:1508399346
Name:PROVENZA, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:PROVENZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-7777
Mailing Address - Fax:336-716-1119
Practice Address - Street 1:MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1900
Practice Address - Country:US
Practice Address - Phone:336-713-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-01626207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program