Provider Demographics
NPI:1508900622
Name:GUILLERMO I ROCHA, MD, PA
Entity Type:Organization
Organization Name:GUILLERMO I ROCHA, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:ISMAEL
Authorized Official - Last Name:ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-922-5922
Mailing Address - Street 1:3727 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-2934
Mailing Address - Country:US
Mailing Address - Phone:210-922-5922
Mailing Address - Fax:210-924-5600
Practice Address - Street 1:3727 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-2934
Practice Address - Country:US
Practice Address - Phone:210-922-5922
Practice Address - Fax:210-924-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6382261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120476004Medicaid