Healthcare Provider Details

I. General information

NPI: 1457369258
Provider Name (Legal Business Name): CHARLES DANIEL PROCTER SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: C DAN PROCTER SR. MD

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8767 PERIMETER PARK BLVD
JACKSONVILLE FL
32216-5479
US

IV. Provider business mailing address

1824 KING ST STE 200
JACKSONVILLE FL
32204-4736
US

V. Phone/Fax

Practice location:
  • Phone: 904-402-8346
  • Fax: 904-402-8347
Mailing address:
  • Phone: 904-384-3343
  • Fax: 904-400-6671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number035736
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: