Provider Demographics
NPI:1811094584
Name:PROVENZANO, MARK PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PHILLIP
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 1:950 CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2804
Mailing Address - Country:US
Mailing Address - Phone:713-464-0077
Mailing Address - Fax:713-464-9582
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
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207XX0005X207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMDG3705OtherLICENSE NUMBER
TX0025EPOtherBCBS PROVIDER #
TX00DE37Medicare PIN
TX0025EPOtherBCBS PROVIDER #