Provider Demographics
NPI:1720261456
Name:MARK PROVENZANO MD PA
Entity Type:Organization
Organization Name:MARK PROVENZANO MD PA
Other - Org Name:THE ORTHOPEDIC SPORTS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING/INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-464-0077
Mailing Address - Street 1:PO BOX 3961
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77253-3961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2804
Practice Address - Country:US
Practice Address - Phone:713-464-0077
Practice Address - Fax:713-464-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3705174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00DE37Medicare UPIN