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General NPI Number Information
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NPI Number | 1649276833
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Entity Type | Individual
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Provider Name | BRIAN PROCTOR D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/22/2005
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Last Update Date | 06/02/2025
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Provider Practice Location Address
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Address Line | 675 W NORTH AVE STE 107
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City | MELROSE PARK
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State | IL
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Zip | 60160-1622
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Country | US
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Telephone | 708-450-4510
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Fax | 708-450-9361
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Provider Business Mailing Address
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Address Line | 675 W NORTH AVE STE 107
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City | MELROSE PARK
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State | IL
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Zip | 60160-1622
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Country | US
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Telephone | 708-450-4510
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Fax | 708-450-9361
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 036089352
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License Number State | IL
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