Provider Demographics
NPI:1831326610
Name:PROCTOR, MATTHEW (MD)
Entity type:Individual
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First Name:MATTHEW
Middle Name:
Last Name:PROCTOR
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Gender:M
Credentials:MD
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Mailing Address - Street 1:15790 PAUL VEGA MD DR
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1434
Mailing Address - Country:US
Mailing Address - Phone:985-230-6700
Mailing Address - Fax:985-230-1528
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-6700
Practice Address - Fax:985-230-1528
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2015-09-24
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Provider Licenses
StateLicense IDTaxonomies
LA390200000X
LA2042142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1950882Medicaid