Provider Demographics
NPI:1386627487
Name:ROUCH, DANIEL R (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:ROUCH
Suffix:
Gender:M
Credentials:DO
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 1018
Mailing Address - Street 2:902 REBEL RD.
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-1018
Mailing Address - Country:US
Mailing Address - Phone:512-268-2091
Mailing Address - Fax:
Practice Address - Street 1:902 FM 150 WEST (REBEL RD)
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640
Practice Address - Country:US
Practice Address - Phone:512-268-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD97682Medicare UPIN
TX00SA47Medicare PIN