Provider Demographics
NPI:1457369258
Name:PROCTER, CHARLES DANIEL SR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DANIEL
Last Name:PROCTER
Suffix:SR
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:DAN
Other - Last Name:PROCTER
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1824 KING ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4736
Mailing Address - Country:US
Mailing Address - Phone:904-384-3343
Mailing Address - Fax:904-400-6671
Practice Address - Street 1:8767 PERIMETER PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5479
Practice Address - Country:US
Practice Address - Phone:904-402-8346
Practice Address - Fax:904-402-8347
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0357362086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000502873KMedicaid
GA592947OtherBCBS
GA1708262OtherWELLCARE
GA000502873JMedicaid
GA000502873MMedicaid
GA000502873TMedicaid
GA01338970OtherAMERIGROUP
GA000502873IMedicaid
GA000502873RMedicaid
GA000502873SMedicaid
GA544229OtherWELLCARE