Provider Demographics
NPI:1629635032
Name:PROCTOR, BRADLEY WAYNE (IDC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:WAYNE
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2205
Mailing Address - Country:US
Mailing Address - Phone:318-572-4557
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:619-532-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman