Provider Demographics
NPI:1417128273
Name:R EDWARD ROYBAL MD PA
Entity Type:Organization
Organization Name:R EDWARD ROYBAL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROYBAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-283-5115
Mailing Address - Street 1:493 WESTPARK WAY
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3957
Mailing Address - Country:US
Mailing Address - Phone:817-283-5115
Mailing Address - Fax:817-267-9519
Practice Address - Street 1:493 WESTPARK WAY
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3957
Practice Address - Country:US
Practice Address - Phone:817-283-5115
Practice Address - Fax:817-267-9519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0598174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00PK75Medicare PIN