Provider Demographics
NPI:1811041734
Name:ROY, RAYMOND JR (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:ROY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12955 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5863
Mailing Address - Country:US
Mailing Address - Phone:503-643-5556
Mailing Address - Fax:503-641-2515
Practice Address - Street 1:12955 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5863
Practice Address - Country:US
Practice Address - Phone:503-643-5556
Practice Address - Fax:503-641-2515
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1005T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18428-3Medicaid
ORR130928Medicare PIN
OR18428-3Medicaid