Provider Demographics
NPI:1598828915
Name:PROCTOR, MICHAEL WAYNE (MD,FAAFP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:MD,FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 QUINTARD AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36201-4619
Mailing Address - Country:US
Mailing Address - Phone:256-741-1339
Mailing Address - Fax:256-741-1356
Practice Address - Street 1:1325 QUINTARD AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-4619
Practice Address - Country:US
Practice Address - Phone:256-741-1339
Practice Address - Fax:256-741-1356
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00011525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51509348OtherBLUE CROSS BLUE SHIELD
AL51509348OtherBLUE CROSS BLUE SHIELD