Provider Demographics
NPI:1043316466
Name:ROACH, MARTIN G (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:G
Last Name:ROACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:7667 AL HWY 51 SUITE B
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801
Mailing Address - Country:US
Mailing Address - Phone:334-737-5557
Mailing Address - Fax:334-737-5646
Practice Address - Street 1:7667 AL HIGHWAY 51 STE B
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36804-2200
Practice Address - Country:US
Practice Address - Phone:334-737-5557
Practice Address - Fax:334-727-5646
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALDO866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
263751277OtherTRICARE
AL51595037OtherBLUE CROSS BLUE SHIELD
263751277OtherTRICARE
AL510I080439Medicare PIN