Healthcare Provider Details

I. General information

NPI: 1245210582
Provider Name (Legal Business Name): JON A PROCTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 12/20/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39141 CIVIC CENTER DR SUITE 350
FREMONT CA
94538-5818
US

IV. Provider business mailing address

1364 BRIONES CT
PLEASANTON CA
94588-5316
US

V. Phone/Fax

Practice location:
  • Phone: 510-248-6900
  • Fax: 510-248-6980
Mailing address:
  • Phone: 510-248-6900
  • Fax: 510-248-6980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberMD00042176
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberG87835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: