Provider Demographics
NPI:1932101128
Name:PROCTOR, BRIAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
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 1:700 WEST AVE SOUTH
Mailing Address - Street 2:ATTN: PHYSICIAN SERVICES
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601
Mailing Address - Country:US
Mailing Address - Phone:608-392-9555
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2848
Practice Address - Country:US
Practice Address - Phone:651-267-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI404722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32497500Medicaid
E78919Medicare UPIN
WI0470Medicare ID - Type Unspecified