Provider Demographics
NPI:1003440223
Name:PROVOSTY, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PROVOSTY
Suffix:
Gender:M
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:PO BOX 86125
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90086-0125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 86125
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90086-0125
Practice Address - Country:US
Practice Address - Phone:323-409-4942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA2004622084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty