Provider Demographics
NPI:1780736041
Name:PROVAN, CAROL JOY
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JOY
Last Name:PROVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 MIDDLEFIELD RD
Mailing Address - Street 2:FAIR OAKS CHILDRENS CLINIC
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063
Mailing Address - Country:US
Mailing Address - Phone:650-573-2222
Mailing Address - Fax:
Practice Address - Street 1:2710 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3404
Practice Address - Country:US
Practice Address - Phone:650-573-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25599208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A255990Medicaid
CA00A255990Medicaid