Provider Demographics
NPI:1063472173
Name:PROCTOR, CARLA RAE (MD)
Entity Type:Individual
Prefix:MISS
First Name:CARLA
Middle Name:RAE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-2200
Mailing Address - Fax:719-553-2222
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2204
Practice Address - Fax:719-553-2222
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-04-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO27054208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01270545Medicaid
COD24892Medicare UPIN