Healthcare Provider Details

I. General information

NPI: 1740796119
Provider Name (Legal Business Name): PAUL JON PROCKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7009 DR PHILLIPS BLVD STE 140
ORLANDO FL
32819-5122
US

IV. Provider business mailing address

1945 SAMANTHA LN
VALRICO FL
33594-5146
US

V. Phone/Fax

Practice location:
  • Phone: 407-412-6973
  • Fax:
Mailing address:
  • Phone: 407-716-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5257
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: