Provider Demographics
NPI:1942431515
Name:PROVENZANO, JOEL D (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:D
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 1:1040 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6416
Mailing Address - Country:US
Mailing Address - Phone:740-375-8135
Mailing Address - Fax:740-375-6468
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-375-8135
Practice Address - Fax:740-375-6468
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.099189207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071205Medicaid
OH0071205Medicaid