Provider Demographics
NPI:1790771103
Name:PROCTOR, E EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:E
Middle Name:EDWARD
Last Name:PROCTOR
Suffix:
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 1:755 WALTHER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8725
Mailing Address - Country:US
Mailing Address - Phone:770-962-0399
Mailing Address - Fax:770-995-0533
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045
Practice Address - Country:US
Practice Address - Phone:770-962-0399
Practice Address - Fax:770-995-0533
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32976207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00430328CMedicaid
GA06BDGDTMedicare ID - Type Unspecified
GA00430328CMedicaid