Healthcare Provider Details

I. General information

NPI: 1629121413
Provider Name (Legal Business Name): FOLSOM PROCTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 J L WHITE DR SUITE 100
JASPER GA
30143-4896
US

IV. Provider business mailing address

620 J L WHITE DR SUITE 100
JASPER GA
30143-4896
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-6980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number035504
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: