Provider Demographics
NPI:1912969817
Name:BLANK, ROY C (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:C
Last Name:BLANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:1995 WELLNESS BLVD
Practice Address - Street 2:SUITE 110, BLDG B
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7769
Practice Address - Country:US
Practice Address - Phone:704-384-1140
Practice Address - Fax:704-384-1141
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC30777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN30777Medicaid
NC8916227Medicaid
NC204843DMedicare ID - Type Unspecified
NC8916227Medicaid