Provider Demographics
NPI:1780871491
Name:PROCTOR DERMATOLOGY & SKIN SURGERY PA
Entity type:Organization
Organization Name:PROCTOR DERMATOLOGY & SKIN SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-345-8050
Mailing Address - Street 1:1609 PASADENA AVE S
Mailing Address - Street 2:SUITE 4 0
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4565
Mailing Address - Country:US
Mailing Address - Phone:727-345-8050
Mailing Address - Fax:727-345-4344
Practice Address - Street 1:1609 PASADENA AVE S
Practice Address - Street 2:SUITE 4 0
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4565
Practice Address - Country:US
Practice Address - Phone:727-345-8050
Practice Address - Fax:727-345-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAH263Medicare PIN