MEDICARE: MR. DAVID KENNETH PROCTOR JR.

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	2472R0900X	Renal Dialysis Technician	DT.005141	OH

General Provider Information

NPI Number	:	1952299901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID KENNETH PROCTOR JR.

Provider Business Mailing Address
First Line	:	4444 MONTICELLO BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44143-2838
Country	:	US
Telephone Number	:	216-536-7677
Fax Number	:

Provider Business Practice Location Address
First Line	:	4444 MONTICELLO BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44143-2838
Country	:	US
Telephone Number	:	216-536-7677
Fax Number	:

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

Provider Enumeration Date	:	06/26/2025
Last Update Date	:	06/26/2025

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