Provider Demographics
NPI:1952308181
Name:PROCTOR, GARY RAY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RAY
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 1:140 CROSSTIDE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4028
Mailing Address - Country:US
Mailing Address - Phone:904-285-4715
Mailing Address - Fax:
Practice Address - Street 1:10199 SOUTHSIDE BLVD
Practice Address - Street 2:BLD 100 SUITE 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0758
Practice Address - Country:US
Practice Address - Phone:800-700-8646
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 717032084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry