Provider Demographics
NPI:1366977027
Name:ROYBAL, LACEY (DO)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:ROYBAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 NW SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3737
Mailing Address - Country:US
Mailing Address - Phone:541-768-4906
Mailing Address - Fax:
Practice Address - Street 1:1793 13TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2541
Practice Address - Country:US
Practice Address - Phone:866-599-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO188595207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology