Provider Demographics
NPI:1982687190
Name:PROCTOR, DEBORAH DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:DENISE
Last Name:PROCTOR
Suffix:
Gender:F
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:PO BOX 208237
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8237
Mailing Address - Country:US
Mailing Address - Phone:203-432-0076
Mailing Address - Fax:203-432-7289
Practice Address - Street 1:55 LOCK STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-432-0076
Practice Address - Fax:203-432-7289
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037149207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001371492Medicaid
CT001371492Medicaid
F37732Medicare UPIN