Provider Demographics
NPI:1679650006
Name:PROCTOR AND PROCTOR PC
Entity Type:Organization
Organization Name:PROCTOR AND PROCTOR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-263-2489
Mailing Address - Street 1:1227 WESTSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1715
Mailing Address - Country:US
Mailing Address - Phone:717-263-2489
Mailing Address - Fax:
Practice Address - Street 1:1227 WESTSIDE AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1715
Practice Address - Country:US
Practice Address - Phone:717-263-2489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036068E207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C33317Medicare UPIN
PA197597Medicare ID - Type Unspecified