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
State | License ID | Taxonomies |
---|---|---|
IA | 36708 | 207Y00000X |
OR | MD27634 | 207Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 274607 | Medicaid | |
OR | 831523003 | Other | REGENCE BLUE CROSS |
WA | 8491839 | Medicaid | |
OR | P00436239 | Other | RAILROAD MEDICARE |
OR | 274607 | Medicaid | |
OR | 139555 | Medicare PIN |