Provider Demographics
NPI:1225215783
Name:PROCTOR, VERNON EUGENE (M D)
Entity Type:Individual
Prefix:DR
First Name:VERNON
Middle Name:EUGENE
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7737
Mailing Address - Country:US
Mailing Address - Phone:231-745-4914
Mailing Address - Fax:231-745-4922
Practice Address - Street 1:1234 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7737
Practice Address - Country:US
Practice Address - Phone:231-745-4914
Practice Address - Fax:231-745-4922
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010893652083P0901X
WAMD00049285207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26239Medicaid
MI0Q26239Medicaid