Provider Demographics
NPI:1851360424
Name:ROY, MARK JOSEPH III (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:ROY
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:640 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-3422
Mailing Address - Country:US
Mailing Address - Phone:985-446-1717
Mailing Address - Fax:985-446-9542
Practice Address - Street 1:640 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-3422
Practice Address - Country:US
Practice Address - Phone:985-446-1717
Practice Address - Fax:985-446-9542
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1354-488T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1128015Medicaid
LA4B272Medicare ID - Type Unspecified
LAU91796Medicare UPIN