Provider Demographics
NPI:1407497076
Name:ROCHA, GUADALUPE (OD)
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:ROCHA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 CENTRAL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2374
Mailing Address - Country:US
Mailing Address - Phone:951-784-2420
Mailing Address - Fax:
Practice Address - Street 1:19530 VAN BUREN BLVD STE G8
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-9456
Practice Address - Country:US
Practice Address - Phone:951-656-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34684TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist