Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 1128 | WV |
NPI | 1225160575 |
---|---|
Provider Name | Dr. David Allen Proctor |
First Address | Beverly, WV 26253 |
Second Address | Beverly, WV 26253 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
EO5907 | (02) | WV |