Provider Demographics
NPI:1215357470
Name:ROACH, KRISTOPHER RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:RICHARD
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTOPHER
Other - Middle Name:RICHARD
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:
Practice Address - Street 1:1955 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6282
Practice Address - Country:US
Practice Address - Phone:480-728-3000
Practice Address - Fax:602-230-6461
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58553207RC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program