Provider Demographics
NPI:1598780488
Name:PROCTER, CHARLES DANIEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DANIEL
Last Name:PROCTER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLEY
Other - Middle Name:DANIEL
Other - Last Name:PROCTER
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2110 POWERS FERRY RD SE STE 302
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5015
Mailing Address - Country:US
Mailing Address - Phone:470-419-4380
Mailing Address - Fax:470-298-7736
Practice Address - Street 1:371 E PACES FERRY RD NE STE 750
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2372
Practice Address - Country:US
Practice Address - Phone:470-419-4380
Practice Address - Fax:470-298-7736
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059108208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7992557OtherCIGNA
GA9243155OtherAETNA
GA52222643OtherBCBS
GA52222643OtherBC/BS OF GEORGIA
GA52222643OtherBC/BS OF GEORGIA
GA550998OtherWELLCARE
GA7992557OtherCIGNA
GA9243155OtherAETNA
GA550998OtherWELLCARE
GA898606045GMedicaid
GA01335741OtherAMERIGROUP
GA898606045EMedicaid
GA202I024333Medicare PIN
GA550998OtherWELLCARE
GA52222643OtherBCBS
GA898606045DMedicaid