Provider Demographics
NPI:1801097019
Name:ROY, DAVID BERNARD (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BERNARD
Last Name:ROY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2362
Mailing Address - Country:US
Mailing Address - Phone:601-336-5626
Mailing Address - Fax:601-336-7826
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2362
Practice Address - Country:US
Practice Address - Phone:601-336-5626
Practice Address - Fax:601-336-7826
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4312207N00000X, 207ND0101X
MS21178207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09652756Medicaid
MS302I076867Medicare Oscar/Certification
AZZ125042Medicare PIN