Provenza, John M
Provenza, John M is an individual health care provider with primary practice located at 8383 Millicent Way Ste B , Shreveport LA 71115. He recently has only one registered license in Allopathic & Osteopathic Physicians / Gastroenterology, which is considered as his primary health care specialty. Provenza, John M can be contacted via phone (318) 631-9121.Contact Information
Primary practice address
8383 Millicent Way Ste B
Shreveport LA 71115
Phone: (318) 631-9121
Fax: (318) 213-6246
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Gastroenterology | 207RG0100X | 017860 | Louisiana |
Profile Details
| NPI number | 1225028434 |
|---|---|
| LBN Legal business name | Provenza, John M |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Oct 27th, 2005 |
| Last updated | Aug 12th, 2022 - about 2 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1225028434 | NPPES |
| Louisiana | Other | MD.017860 | STATE LICENSE |
| Louisiana | MEDICAID | 1376442 | STATE LICENSE |
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