Healthcare Provider Details

I. General information

NPI: 1316971575
Provider Name (Legal Business Name): KRISTA LYDIA ROYBAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 EXECUTIVE DR STE 225
SAN DIEGO CA
92121-3094
US

IV. Provider business mailing address

4520 EXECUTIVE DR STE 225
SAN DIEGO CA
92121-3094
US

V. Phone/Fax

Practice location:
  • Phone: 858-202-1822
  • Fax: 858-202-4421
Mailing address:
  • Phone: 858-202-1822
  • Fax: 858-202-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2005-0004
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA103600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: