Provider Demographics
NPI:1003010380
Name:MARTIN M ROCHE MD PA
Entity Type:Organization
Organization Name:MARTIN M ROCHE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-462-7558
Mailing Address - Street 1:500 SE 17TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2547
Mailing Address - Country:US
Mailing Address - Phone:954-462-7558
Mailing Address - Fax:954-525-5820
Practice Address - Street 1:500 SE 17TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2547
Practice Address - Country:US
Practice Address - Phone:954-462-7558
Practice Address - Fax:954-525-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06962OtherBLUECROSS OF FLORIDA
FL06962Medicare ID - Type Unspecified
FLB75132Medicare UPIN