Provider Demographics
NPI:1649276833
Name:PROCTOR, BRIAN (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:PROCTOR
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Gender:M
Credentials:DO
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Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1622
Mailing Address - Country:US
Mailing Address - Phone:708-450-4510
Mailing Address - Fax:708-450-9361
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:STE 107
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1622
Practice Address - Country:US
Practice Address - Phone:708-450-4510
Practice Address - Fax:708-450-9361
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036089352207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
180029414OtherRAILROAD MEDICARE
IL036089352Medicaid