Provider Demographics
NPI:1932127412
Name:PROCTOR, MATTHEW DAVID (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
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 1:1815 E 19TH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3385
Mailing Address - Country:US
Mailing Address - Phone:541-298-5563
Mailing Address - Fax:541-298-7746
Practice Address - Street 1:1815 E 19TH ST
Practice Address - Street 2:STE 1
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3385
Practice Address - Country:US
Practice Address - Phone:541-298-5563
Practice Address - Fax:541-298-7746
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36708207Y00000X
ORMD27634207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274607Medicaid
OR831523003OtherREGENCE BLUE CROSS
WA8491839Medicaid
ORP00436239OtherRAILROAD MEDICARE
OR274607Medicaid
OR139555Medicare PIN