Provider Demographics
NPI:1700376092
Name:PROCTOR, CHARLES NELSON IV (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:NELSON
Last Name:PROCTOR
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ESTEMERWALT DR
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-3032
Mailing Address - Country:US
Mailing Address - Phone:650-862-9942
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-222-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-13
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program