Provider Demographics
NPI:1174514327
Name:ROY, MARK WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:ROY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0488
Mailing Address - Country:US
Mailing Address - Phone:336-623-9711
Mailing Address - Fax:336-627-0778
Practice Address - Street 1:518 S VAN BUREN RD
Practice Address - Street 2:SUITE 6
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5033
Practice Address - Country:US
Practice Address - Phone:336-623-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36816207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8973551Medicaid
NC8973551Medicaid
NC2185875Medicare ID - Type Unspecified