Healthcare Provider Details

I. General information

NPI: 1558348839
Provider Name (Legal Business Name): ROY CARL ST JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 MOUNT VERNON AVE
COLUMBUS OH
43203-1408
US

IV. Provider business mailing address

788 MOUNT VERNON AVE
COLUMBUS OH
43203-1408
US

V. Phone/Fax

Practice location:
  • Phone: 614-457-4570
  • Fax: 614-457-3777
Mailing address:
  • Phone: 614-457-4570
  • Fax: 614-457-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35054825S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: