Provider Demographics
NPI:1942486428
Name:PROVENZANO, MARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3979TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
80775QOtherBC/BS TX
1073607370OtherRAILROAD MEDICARE
TX00Z950Medicare PIN
T92687Medicare UPIN
80775QOtherBC/BS TX
TX8F9342Medicare PIN
0328270001Medicare NSC