Provider Demographics
NPI:1124541719
Name:ROACH, BENJAMIN G (OD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:G
Last Name:ROACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17450 ST LUKES WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8045
Mailing Address - Country:US
Mailing Address - Phone:281-363-3443
Mailing Address - Fax:936-271-1351
Practice Address - Street 1:17450 ST LUKES WAY STE 100
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8045
Practice Address - Country:US
Practice Address - Phone:281-363-3443
Practice Address - Fax:936-271-1351
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9164T152W00000X
TX9164TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist