Provider Demographics
NPI:1649274259
Name:ROYALTY, JOHN WAYNE (DO)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WAYNE
Last Name:ROYALTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3402 N LECANTO HWY
Mailing Address - Street 2:STE C
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3570
Mailing Address - Country:US
Mailing Address - Phone:352-563-5488
Mailing Address - Fax:352-563-6328
Practice Address - Street 1:3402 N LECANTO HWY
Practice Address - Street 2:STE C
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3570
Practice Address - Country:US
Practice Address - Phone:352-563-5488
Practice Address - Fax:352-563-6328
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL056237208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372553700Medicaid
FL372553700Medicaid
FL372553700Medicaid