Provider Demographics
NPI:1669474615
Name:ROYSTER, ROBERT MARVIA (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARVIA
Last Name:ROYSTER
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 1:2001 PEACHTREE RD NE
Mailing Address - Street 2:STE 705
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-355-0743
Mailing Address - Fax:404-355-2136
Practice Address - Street 1:2001 PEACHTREE RD NE
Practice Address - Street 2:STE 705
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-355-0743
Practice Address - Fax:404-355-2136
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023401207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00406293BMedicaid
GA00406293BMedicaid
GA20BDBSCMedicare ID - Type Unspecified