Provider Demographics
NPI:1376503474
Name:ROACH, JOHN G III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:ROACH
Suffix:III
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-7800
Mailing Address - Fax:336-718-7900
Practice Address - Street 1:105 VEST MILL CIR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2943
Practice Address - Country:US
Practice Address - Phone:336-718-7800
Practice Address - Fax:336-718-7900
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC21859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8971910Medicaid
NC209940BMedicare ID - Type Unspecified
NC8971910Medicaid