Provider Demographics
NPI:1043219405
Name:PROCTOR, DONALD (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:PROCTOR
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 1:2206 E OCEAN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-3104
Mailing Address - Country:US
Mailing Address - Phone:772-567-1164
Mailing Address - Fax:772-770-0799
Practice Address - Street 1:1325 36TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6599
Practice Address - Country:US
Practice Address - Phone:772-567-1164
Practice Address - Fax:772-770-0799
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064734207ND0101X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28426OtherBLUE CROSS
FLG27618Medicare UPIN
FL28426ZMedicare ID - Type Unspecified