Provider Demographics
NPI:1780799775
Name:DAVID G PROVAZNIK DO INC
Entity type:Organization
Organization Name:DAVID G PROVAZNIK DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:PROVAZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-574-4526
Mailing Address - Street 1:11826 GALLIA PIKE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-9119
Mailing Address - Country:US
Mailing Address - Phone:740-574-4526
Mailing Address - Fax:740-574-2895
Practice Address - Street 1:11826 GALLIA PIKE RD
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0965915Medicaid
OHE12727Medicare UPIN
OH0709963Medicare PIN