Provider Demographics
NPI:1740418409
Name:ROYAL, MIKE A (MD JD MBA)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:A
Last Name:ROYAL
Suffix:
Gender:M
Credentials:MD JD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4533 OCEAN VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2428
Mailing Address - Country:US
Mailing Address - Phone:858-794-4975
Mailing Address - Fax:
Practice Address - Street 1:12481 HIGH BLUFF DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3585
Practice Address - Country:US
Practice Address - Phone:858-436-1427
Practice Address - Fax:858-436-1401
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86767207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE74036Medicare UPIN