Provider Demographics
NPI:1346278264
Name:PROVO, JAMES E (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:PROVO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:180 JOHN F KENNEDY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6641
Mailing Address - Country:US
Mailing Address - Phone:561-967-6500
Mailing Address - Fax:561-314-7201
Practice Address - Street 1:4705 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-5135
Practice Address - Country:US
Practice Address - Phone:561-220-2622
Practice Address - Fax:561-257-1922
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME67309207P00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377506200Medicaid
FL27095OtherBLUE CROSS BLUE SHIELD
FL27095MMedicare PIN
FL377506200Medicaid