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Contact Information

MARK A PROVENZANO, OD
123 CIRCLE WAY
LAKE JACKSON, TX77566-5233
 Phone: 979-299-3250
 Fax:
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

Optometrist

152W00000X 41 Optometry
Indicates primary specialty

NPI Profile & details for MARK A PROVENZANO · (Male)

NPI # 1942486428
Status Active
Credentials OD (Doctor of Optometry)
Entity Individual
Enumeration date 01/15/2008
Last updated 04/21/2009 - About 17 years ago
Sole proprietor 1 Yes
Identifiers
  • TX License # 3979TG
  • Other 80775Q BC/BS TX
  • Other 1073607370 RAILROAD MEDICARE
Hospital affiliation(s) Not Available
1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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