Provider Demographics
NPI:1831391804
Name:ROY A. DEFRIES, M.D., L.L.C.
Entity type:Organization
Organization Name:ROY A. DEFRIES, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEFRIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-682-3138
Mailing Address - Street 1:3524 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-3320
Mailing Address - Country:US
Mailing Address - Phone:812-425-1555
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100246950BMedicaid
IN194630Medicare ID - Type Unspecified
IN100246950BMedicaid