Provider Demographics
NPI:1245267624
Name:PROVAZNIK, DAVID GERARD (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GERARD
Last Name:PROVAZNIK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:740-574-4526
Mailing Address - Fax:740-574-2895
Practice Address - Street 1:11826 GALLIA PIKE
Practice Address - Street 2:SUITE A
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-9119
Practice Address - Country:US
Practice Address - Phone:740-574-4526
Practice Address - Fax:740-574-2895
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-02-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH34005337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0842315Medicaid
OH0842315Medicaid
OH0709969Medicare PIN
OHE12727Medicare UPIN