Provider Demographics
NPI:1083717516
Name:FUQUAY OPHTHALMOLOGY AND GLAUCOMA PC
Entity Type:Organization
Organization Name:FUQUAY OPHTHALMOLOGY AND GLAUCOMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-567-3709
Mailing Address - Street 1:605 ATTAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1972
Mailing Address - Country:US
Mailing Address - Phone:919-567-3709
Mailing Address - Fax:919-567-3710
Practice Address - Street 1:605 ATTAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1972
Practice Address - Country:US
Practice Address - Phone:919-567-3709
Practice Address - Fax:919-567-3710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014WMMedicaid
NC89014WMMedicaid