Provider Demographics
NPI:1174517403
Name:PROVANCE, WILLIAM J (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:PROVANCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:681 GOODLETTE RD N
Practice Address - Street 2:STE 130
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5458
Practice Address - Country:US
Practice Address - Phone:239-643-9767
Practice Address - Fax:239-649-5878
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2014-09-04
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2007-08-03
Provider Licenses
StateLicense IDTaxonomies
FLOS12406207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00252222OtherPALMETTOGBA
PA0013977160006Medicaid
009945Medicare Oscar/Certification
PAP00252222OtherPALMETTOGBA
PA125483Medicare ID - Type Unspecified
PA0013977160006Medicaid