Provider Demographics
NPI:1871001818
Name:ROY, KEVIN JONATHAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JONATHAN
Last Name:ROY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5958 DELAFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1608
Mailing Address - Country:US
Mailing Address - Phone:914-512-0938
Mailing Address - Fax:
Practice Address - Street 1:5958 DELAFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1608
Practice Address - Country:US
Practice Address - Phone:914-512-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00152500213E00000X
NY003515213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MD00152500OtherSTATE LICENSE
NY003515OtherLICENSE
CA3090OtherSTATE LICENSE