Provider Demographics
NPI:1639134174
Name:ROCHE, BERTRAND P (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAND
Middle Name:P
Last Name:ROCHE
Suffix:
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 1:61 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2918
Mailing Address - Country:US
Mailing Address - Phone:716-565-1234
Mailing Address - Fax:716-565-1246
Practice Address - Street 1:61 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2918
Practice Address - Country:US
Practice Address - Phone:716-565-1234
Practice Address - Fax:716-565-1246
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0108357OtherINDEPEDENT HEALTH
NY00010149101OtherUNIVERA
NY0108357OtherINDEPEDENT HEALTH
B36069Medicare UPIN