Provider Demographics
NPI:1881655793
Name:DEFRIES, ROY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:ALLEN
Last Name:DEFRIES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LEROY
Other - Middle Name:ALLEN
Other - Last Name:DEFRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5565 MAPLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARMONY
Mailing Address - State:IN
Mailing Address - Zip Code:47631-9303
Mailing Address - Country:US
Mailing Address - Phone:812-682-3138
Mailing Address - Fax:812-425-1815
Practice Address - Street 1:3524 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-3320
Practice Address - Country:US
Practice Address - Phone:812-425-1555
Practice Address - Fax:812-425-1815
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100246950BMedicaid
IN194630Medicare ID - Type Unspecified
IN100246950BMedicaid