Individual
MARK PHILLIP PROVENZANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
950 CAMPBELL RD, HOUSTON, TX 77024-2804
(713) 464-0077
(713) 464-9582
Mailing address
950 CAMPBELL RD, HOUSTON, TX 77024-2804
(713) 464-0077
(713) 464-9582
Taxonomy
Speciality
Code
Description
License number
State
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
Primary
207XX0005X
TX
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
Primary
G3705
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0025EP
BCBS PROVIDER #
TX
01
—
MDG3705
LICENSE NUMBER
TX
Enumeration date
09/17/2006
Last updated
03/04/2026
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