Provider Demographics
NPI:1083622294
Name:ROY, SUBIR (MD)
Entity Type:Individual
Prefix:
First Name:SUBIR
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031
Mailing Address - Country:US
Mailing Address - Phone:323-221-3270
Mailing Address - Fax:323-225-6284
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-865-3979
Practice Address - Fax:323-265-0062
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24383207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A243830Medicaid
1992740450OtherGROUP NPI
CAA24383OtherSTATE LICENSE
CA00A243830OtherBLUE SHIELD
1992740450OtherGROUP NPI