Provider Demographics
NPI:1255315164
Name:ROCHE, WARREN P JR (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:P
Last Name:ROCHE
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 1:200 W OLLIE
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:TX
Mailing Address - Zip Code:78643-2628
Mailing Address - Country:US
Mailing Address - Phone:325-247-5040
Mailing Address - Fax:325-248-2108
Practice Address - Street 1:100 PECAN CROSSING
Practice Address - Street 2:
Practice Address - City:HORSESHOE BAY
Practice Address - State:TX
Practice Address - Zip Code:78657
Practice Address - Country:US
Practice Address - Phone:830-598-4405
Practice Address - Fax:830-598-5172
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8742207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82372OtherSCOTT AND WHITE
TX042989604Medicaid
TX8F9830OtherBCBS
TX042989602Medicaid
TX130874101OtherFIRSTCARE
G46180Medicare UPIN
TX042989602Medicaid
TX042989604Medicaid