Provider Demographics
NPI:1265501779
Name:PROCTOR, MICHAEL RAY (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3015 HIGHWAY 95
Mailing Address - Street 2:#110
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442
Mailing Address - Country:US
Mailing Address - Phone:928-758-8885
Mailing Address - Fax:928-758-2424
Practice Address - Street 1:3015 HIGHWAY 95
Practice Address - Street 2:#110
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-758-8885
Practice Address - Fax:928-758-2424
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3378207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ24392Medicare PIN
E45334Medicare UPIN