Provider Demographics
NPI:1952299901
Name:PROCTOR, DAVID KENNETH JR
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KENNETH
Last Name:PROCTOR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 MONTICELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2838
Mailing Address - Country:US
Mailing Address - Phone:216-536-7677
Mailing Address - Fax:
Practice Address - Street 1:4444 MONTICELLO BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44143-2838
Practice Address - Country:US
Practice Address - Phone:216-536-7677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDT.0051412472R0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis