Provider Demographics
NPI:1972399426
Name:PROVOST, JAMIE STEPHEN II (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:STEPHEN
Last Name:PROVOST
Suffix:II
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 OAK LN
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-2303
Mailing Address - Country:US
Mailing Address - Phone:214-914-8817
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7200
Practice Address - Country:US
Practice Address - Phone:214-648-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program