Provider Demographics
NPI:1225028434
Name:PROVENZA, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:PROVENZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3217 MABEL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4022
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9126
Practice Address - Street 1:8383 MILLICENT WAY STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-213-6246
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA017860207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.017860OtherSTATE LICENSE
LA1376442Medicaid
LAB64555Medicare UPIN
LA1376442Medicaid
LA263526YTS0Medicare PIN