Healthcare Provider Details

I. General information

NPI: 1497320584
Provider Name (Legal Business Name): LUKE PROCTOR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PENNSYLVANIA ST
ORLANDO FL
32806-2937
US

IV. Provider business mailing address

51 PENNSYLVANIA ST
ORLANDO FL
32806-2937
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-3220
  • Fax: 321-843-3210
Mailing address:
  • Phone: 321-843-3220
  • Fax: 321-843-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS20895
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: