Provider Demographics
NPI:1174880074
Name:ROYSTON, IVOR (MD)
Entity type:Individual
Prefix:
First Name:IVOR
Middle Name:
Last Name:ROYSTON
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 1:9393 TOWNE CENTRE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3070
Mailing Address - Country:US
Mailing Address - Phone:858-964-5004
Mailing Address - Fax:858-362-1051
Practice Address - Street 1:9393 TOWNE CENTRE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3070
Practice Address - Country:US
Practice Address - Phone:858-964-5004
Practice Address - Fax:858-362-1051
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist