Provider Demographics
NPI:1356425292
Name:ROYSTER, LETITIA D (MD)
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:D
Last Name:ROYSTER
Suffix:
Gender:F
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 962380
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6921
Mailing Address - Country:US
Mailing Address - Phone:770-996-1200
Mailing Address - Fax:770-907-7492
Practice Address - Street 1:81 UPPER RIVERDALE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2627
Practice Address - Country:US
Practice Address - Phone:770-996-1200
Practice Address - Fax:770-907-7492
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044077207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00757402AMedicaid
GAF65873Medicare UPIN
GA16BDGBRMedicare ID - Type Unspecified