Provider Demographics
NPI:1972505584
Name:PROVENZANO, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
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 1:1840 E RAY RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:855-397-0197
Mailing Address - Fax:800-272-6512
Practice Address - Street 1:1547 NE 40TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1862
Practice Address - Country:US
Practice Address - Phone:855-397-0197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11205207RN0300X
MI4301047354207RN0300X
AZ54729207RN0300X
NC2017-00405207RN0300X
SC40429207RN0300X
PAMD463387207RN0300X
FLME118456207RN0300X
CO48234207RN0300X
TNMD0000053388207RN0300X
ORMD170613207RN0300X
MIRP047354207RN0300X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4871OtherPTAN
COCOB4871OtherPTAN
COCOB4871OtherPTAN