Provider Demographics
NPI:1083680896
Name:ROACH, JAMES JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JOSEPH
Last Name:ROACH
Suffix:JR
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 1:201 S. BUENA VISTA ST.
Mailing Address - Street 2:SUITE 440
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-842-4819
Mailing Address - Fax:818-842-2086
Practice Address - Street 1:201 S. BUENA VISTA ST.
Practice Address - Street 2:SUITE 440
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-842-4819
Practice Address - Fax:818-842-2086
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35197173000000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77466ZMedicaid
290003061OtherPTAN (RAILROAD MCARE)
CAZZZ77466ZMedicaid