Provider Demographics
NPI:1457369258
Name:PROCTER, CHARLES DANIEL SR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DANIEL
Last Name:PROCTER
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:DAN
Other - Last Name:PROCTER
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:786-207-4000
Practice Address - Fax:770-531-2435
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0357362086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000502873KMedicaid
GA000502873MMedicaid
GA000502873IMedicaid
GA000502873JMedicaid
GA000502873SMedicaid
GA592947OtherBCBS
GA000502873RMedicaid
GA000502873TMedicaid
GA01338970OtherAMERIGROUP
GA1708262OtherWELLCARE
GA544229OtherWELLCARE