Provider Demographics
NPI:1275758450
Name:PROCTOR, EVA GAIL (MD)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:GAIL
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:7655 POPLAR AVE
Practice Address - Street 2:BUILDING A, SUITE 350
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3957
Practice Address - Country:US
Practice Address - Phone:901-761-2470
Practice Address - Fax:901-767-4898
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43277208G00000X
MS20949208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR173361001Medicaid
TN1514503Medicaid
TN4340896OtherBCBS
MS00338543Medicaid
TN1514503Medicaid
AR173361001Medicaid