Healthcare Provider Details

I. General information

NPI: 1710940713
Provider Name (Legal Business Name): ROYCE E LOVERN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 HICKORY LN
WASHINGTON MO
63090-1222
US

IV. Provider business mailing address

128 HICKORY LN
WASHINGTON MO
63090-1222
US

V. Phone/Fax

Practice location:
  • Phone: 314-307-1968
  • Fax:
Mailing address:
  • Phone: 314-307-1968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR5B95
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: