Provider Demographics
NPI:1790707172
Name:PROCTOR, JOSEPH CHARLES SR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CHARLES
Last Name:PROCTOR
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3881 BEAR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-4374
Mailing Address - Country:US
Mailing Address - Phone:928-505-4945
Mailing Address - Fax:928-505-3338
Practice Address - Street 1:1200 W MOHAVE RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-6349
Practice Address - Country:US
Practice Address - Phone:928-669-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3165207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE24059Medicare UPIN