Provider Demographics
NPI:1972553790
Name:ROYSTER, RANDOLPH L JR (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:L
Last Name:ROYSTER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:600 HOSPITAL DR
Practice Address - Street 2:SUITE 10
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-8046
Practice Address - Country:US
Practice Address - Phone:828-452-2320
Practice Address - Fax:828-456-4707
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC197172085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130TYOtherBCBS OF NC PROVIDER #
NC8770417002OtherCIGNA PROVIDER NUMBER
NC4626651OtherAETNA PROVIDER NUMBER
NC92-0006817OtherRAILROAD MCARE PROVIDER #
FL1190948OtherGATEWAY HEALTH
NC24-00057OtherUTD. HLTHCR PROVIDER #
NC89130TYMedicaid
NCB4334OtherMEDCOST PROVIDER NUMBER
NC24-00057OtherUTD. HLTHCR PROVIDER #
NC2297387Medicare ID - Type Unspecified