Provider Demographics
NPI:1750406781
Name:ROY, PHILLIP E (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:E
Last Name:ROY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15145 POMONA RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005
Mailing Address - Country:US
Mailing Address - Phone:262-797-9322
Mailing Address - Fax:262-797-9648
Practice Address - Street 1:17495 W CAPITOL DR STE D
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2059
Practice Address - Country:US
Practice Address - Phone:262-797-9638
Practice Address - Fax:262-797-9648
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1966152W00000X
WI391547996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT63157Medicare UPIN
WI000087490Medicare PIN