Provider Demographics
NPI:1164451407
Name:PROCTOR, MATTHEW TODD (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:2026 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5822
Practice Address - Country:US
Practice Address - Phone:903-586-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160029802Medicaid
TXP00688868OtherRAIL ROAD
TXP01304431OtherRAIL ROAD
TX160029801Medicaid
TX752616977113OtherTRICARE
TX75-2616977-113OtherTRICARE
TX8DZ886OtherBCBS BLUE
TX152404312Medicaid
TX75-2616977-002OtherTRICARE
TX160029802Medicaid
TX152404312Medicaid