Healthcare Provider Details

I. General information

NPI: 1205790599
Provider Name (Legal Business Name): MAURICE PROCTOR JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 LENFANT SQ SE
WASHINGTON DC
20020-6724
US

IV. Provider business mailing address

3790 MARTIN LUTHER KING JR AVE SE APT B7
WASHINGTON DC
20032-1574
US

V. Phone/Fax

Practice location:
  • Phone: 704-293-5639
  • Fax:
Mailing address:
  • Phone: 704-293-5639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: