Provider Demographics
NPI:1194974816
Name:ROYALS, CHESTER THEO JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:THEO
Last Name:ROYALS
Suffix:JR
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 1:1100 WARD STREET EXT W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 DOCTORS DR STE C
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2211
Practice Address - Country:US
Practice Address - Phone:912-384-5832
Practice Address - Fax:912-383-8279
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA072653OtherMEDICAL LICENSE
GA003150454AMedicaid