Provider Demographics
NPI:1194124834
Name:DAVID B ROY DO PA
Entity type:Organization
Organization Name:DAVID B ROY DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-336-5626
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2362
Mailing Address - Country:US
Mailing Address - Phone:318-884-9706
Mailing Address - Fax:
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2362
Practice Address - Country:US
Practice Address - Phone:318-884-9706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21178207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09537875Medicaid
MS1194124834OtherGROUP NPI
MS595626050OtherBC/BS OF MS
MS09537875Medicaid