Healthcare Provider Details

I. General information

NPI: 1194124834
Provider Name (Legal Business Name): DAVID B ROY DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E HOSPITAL DR
HATTIESBURG MS
39402-1310
US

IV. Provider business mailing address

102 E HOSPITAL DR
HATTIESBURG MS
39402-1310
US

V. Phone/Fax

Practice location:
  • Phone: 601-475-9968
  • Fax: 601-475-9969
Mailing address:
  • Phone: 601-475-9968
  • Fax: 601-475-9969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number21178
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHARITY ELLINGTON
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 601-475-9968