Provider Demographics
NPI:1104832070
Name:PHILLIPS, ROY (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 CLAIREMONT DR
Mailing Address - Street 2:#7
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117
Mailing Address - Country:US
Mailing Address - Phone:858-272-1091
Mailing Address - Fax:858-362-1231
Practice Address - Street 1:3670 CLAIREMONT DR
Practice Address - Street 2:#7
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117
Practice Address - Country:US
Practice Address - Phone:858-272-1091
Practice Address - Fax:858-362-1231
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1394213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1394Medicare ID - Type Unspecified
T10934Medicare UPIN