Provider Demographics
NPI:1841271624
Name:PROCTOR, CONRAD A (MD)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:A
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2251 N SQUIRREL RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-4600
Mailing Address - Country:US
Mailing Address - Phone:248-648-8100
Mailing Address - Fax:248-648-8060
Practice Address - Street 1:2251 N SQUIRREL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-4600
Practice Address - Country:US
Practice Address - Phone:248-648-8100
Practice Address - Fax:248-648-8060
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301023795207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
040637019OtherBCBSM
MI4354759 TYPE 10Medicaid
MI0M23890002Medicare PIN
MI4354759 TYPE 10Medicaid