Basic Information
| Provider Information | |||||||||
| NPI: | 1083622294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROY | ||||||||
| FirstName: | SUBIR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31309 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232213270 | ||||||||
| FaxNumber: | 3232256284 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238653979 | ||||||||
| FaxNumber: | 3232650062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A24383 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | A24383 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00A243830 | 05 | CA | MEDICAID | 1992740450 | 01 | GROUP NPI | OTHER | A24383 | 01 | CA | STATE LICENSE | OTHER | 00A243830 | 01 | CA | BLUE SHIELD | OTHER |