Mark A Provenzano, O.D.

Primary specialty

OptometristTaxonomy code 152W00000X

License

3979TG Issued in TX

Practice address

123 Circle Way
Lake Jackson, TX 77566-5233

Phone

(979) 299-3250

NPI assigned

Jan 15, 2008

Last updated

Apr 21, 2009By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Optometry

Education

University of Houston - College of Optometry, 1988

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Brazosport Professional Eye Clinic Inc

  dba Mark A Provenzano OD

  • Optometrist
  • Lake Jackson, TX
  • NPI 1073607370
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1200355200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1240272000000",
    "number": "1942486428",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "123 CIRCLE WAY",
            "city": "LAKE JACKSON",
            "state": "TX",
            "postal_code": "775665233",
            "telephone_number": "979-299-3250"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "123 CIRCLE WAY",
            "city": "LAKE JACKSON",
            "state": "TX",
            "postal_code": "775665233",
            "telephone_number": "979-299-3250"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PROVENZANO",
        "first_name": "MARK",
        "middle_name": "A",
        "name_prefix": "Dr.",
        "credential": "O.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-01-15",
        "last_updated": "2009-04-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "TX",
            "license": "3979TG",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "1073607370",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS TX",
            "identifier": "80775Q",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Premier Family Health and Wellness PLLC
• Prezas Family Medicine, P.a.
• Roland Prezas, D.O.
• Leah Price, OTR
• Primary Care Associates of Lake Jackson, PLLC
• Quad/Med, LLC
• R. Kattegummula, M.D, P.a.
• Raj Dalal MD PA
• Emily Ramirez, DC
• Ramitra Dental Implants & Periodontics PLLC

• Optometrist in Lake Jackson, TX
• Providers in Lake Jackson, TX by specialty
• Optometrist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 21, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.