Provider Demographics
NPI:1740329259
Name:PROCTOR, DEWAYNE TROY
Entity type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:TROY
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:IDA
Other - Middle Name:RAE
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:1101 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-4059
Mailing Address - Country:US
Mailing Address - Phone:662-588-5283
Mailing Address - Fax:
Practice Address - Street 1:1101 SMITH AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-4059
Practice Address - Country:US
Practice Address - Phone:662-588-5283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSB1208544332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies