Provider Demographics
NPI:1205838166
Name:PROKOS, CRAIG P (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:P
Last Name:PROKOS
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 1:136 JUPITER LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7180
Mailing Address - Country:US
Mailing Address - Phone:561-746-3030
Mailing Address - Fax:561-746-0771
Practice Address - Street 1:136 JUPITER LAKES BLVD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7180
Practice Address - Country:US
Practice Address - Phone:561-746-3030
Practice Address - Fax:561-746-0771
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2015-04-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
FLME32958207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30174Medicare ID - Type Unspecified
FLD21460Medicare UPIN