Basic Information
| Provider Information | |||||||||
| NPI: | 1457369258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROCTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROCTER | ||||||||
| OtherFirstName: | C | ||||||||
| OtherMiddleName: | DAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | SR. | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782074000 | ||||||||
| FaxNumber: | 7705312435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 035736 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000502873R | 05 | GA | MEDICAID | 000502873T | 05 | GA | MEDICAID | 000502873M | 05 | GA | MEDICAID | 1708262 | 01 | GA | WELLCARE | OTHER | 000502873I | 05 | GA | MEDICAID | 000502873K | 05 | GA | MEDICAID | 01338970 | 01 | GA | AMERIGROUP | OTHER | 000502873S | 05 | GA | MEDICAID | 544229 | 01 | GA | WELLCARE | OTHER | 592947 | 01 | GA | BCBS | OTHER | 000502873J | 05 | GA | MEDICAID |