Provider Demographics
NPI:1609869940
Name:PROVENZANO, JOSEPH M (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:PROVENZANO
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 1:906 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-5671
Mailing Address - Country:US
Mailing Address - Phone:561-736-7330
Mailing Address - Fax:561-736-7388
Practice Address - Street 1:906 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-5671
Practice Address - Country:US
Practice Address - Phone:561-736-7330
Practice Address - Fax:561-736-7388
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50967Medicare UPIN
D50967Medicare UPIN