Provider Demographics
NPI:1215958459
Name:ROY, PRAVEEN (MD)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:ROY
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 1:2841 DEBARR RD STE 50
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2945
Mailing Address - Country:US
Mailing Address - Phone:907-276-2811
Mailing Address - Fax:907-276-2810
Practice Address - Street 1:2841 DEBARR RD STE 50
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2945
Practice Address - Country:US
Practice Address - Phone:907-276-2811
Practice Address - Fax:907-276-2810
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017171207RG0100X
LAMD.203593207RG0100X
WI55751207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00342850OtherRR MEDICARE
MO209956OtherBLUE SHIELD
MO201151206Medicaid
LA2110187Medicaid
MS00531049Medicaid
MO753815OtherHEALTHLINK
MOP00420900OtherRAILROAD MEDICARE
MS00531049Medicaid
MO959825236Medicare PIN
MOI24651Medicare UPIN
MO959821879Medicare PIN
4M9406629Medicare PIN