Provider Demographics
NPI:1689711665
Name:ROACH, MICHAEL P (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:ROACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2520
Mailing Address - Country:US
Mailing Address - Phone:219-413-5100
Mailing Address - Fax:219-465-9502
Practice Address - Street 1:1001 STURDY RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4126
Practice Address - Country:US
Practice Address - Phone:219-462-7173
Practice Address - Fax:219-462-7504
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002513152W00000X
IN18002513A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200853920Medicaid
INU35011Medicare UPIN