Provider Demographics
NPI:1316114564
Name:PROCTOR, GWENDOLYN HOLDINESS (MD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:HOLDINESS
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:STE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-9997
Practice Address - Street 1:1825 N 18TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4420
Practice Address - Country:US
Practice Address - Phone:318-807-3700
Practice Address - Fax:318-807-0014
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2011-09-07
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Provider Licenses
StateLicense IDTaxonomies
LA204506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05818Medicaid