MEDICARE: DR. CHARLES DANIEL PROCTER JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	059108	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7992557	OTHER	GA	CIGNA
2	9243155	OTHER	GA	AETNA
3	52222643	OTHER	GA	BCBS
4	52222643	OTHER	GA	BC/BS OF GEORGIA

General Provider Information

NPI Number	:	1598780488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES DANIEL PROCTER JR. MD

Provider Business Mailing Address
First Line	:	2110 POWERS FERRY RD SE STE 302
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-5015
Country	:	US
Telephone Number	:	470-419-4380
Fax Number	:	470-298-7736

Provider Business Practice Location Address
First Line	:	371 E PACES FERRY RD NE STE 750
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2372
Country	:	US
Telephone Number	:	470-419-4380
Fax Number	:	470-298-7736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	09/19/2022

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