Provider Demographics
NPI:1104894286
Name:HUTAIN, ROYCE LEWIS (MD)
Entity type:Individual
Prefix:
First Name:ROYCE
Middle Name:LEWIS
Last Name:HUTAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-2744
Mailing Address - Country:US
Mailing Address - Phone:714-992-2730
Mailing Address - Fax:714-992-1918
Practice Address - Street 1:955 W IMPERIAL HWY STE 110
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3814
Practice Address - Country:US
Practice Address - Phone:714-449-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G359070Medicaid
WG35907BMedicare PIN
CA00G359070Medicaid