Provider Demographics
NPI:1730382821
Name:ROYAL, JEREMY TODD (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
Last Name:ROYAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 GLENRIDGE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1365
Mailing Address - Country:US
Mailing Address - Phone:678-553-7783
Mailing Address - Fax:678-553-7793
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-851-6323
Practice Address - Fax:404-303-3747
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL285892085R0202X
SCMD363072085R0202X
GA673122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051116335OtherBCBS
AL129081Medicaid
AL051116340OtherBCBS
AL051116342OtherBCBS
AL051116344OtherBCBS
AL129079Medicaid
AL129080Medicaid
AL129084Medicaid
AL051116334OtherBCBS
AL129088Medicaid
AL051116336OtherBCBS
AL051116341OtherBCBS
AL051116333OtherBCBS
AL129087Medicaid
AL051116343OtherBCBS
MS06104821Medicaid
AL129082Medicaid
AL129086Medicaid
AL051116339OtherBCBS
AL129083Medicaid
AL129085Medicaid
AL129088Medicaid