Provider Demographics
NPI:1225160575
Name:PROCTOR, DAVID ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
Last Name:PROCTOR
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 1:1 WHITETAIL COVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:WV
Mailing Address - Zip Code:26253
Mailing Address - Country:US
Mailing Address - Phone:304-636-5861
Mailing Address - Fax:
Practice Address - Street 1:1 WHITETAIL COVE
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:WV
Practice Address - Zip Code:26253
Practice Address - Country:US
Practice Address - Phone:304-636-5861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1128207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVEO5907Medicare UPIN