Provider Demographics
NPI:1700821907
Name:ROA, RICARDO A (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:A
Last Name:ROA
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631
Mailing Address - Country:US
Mailing Address - Phone:740-886-9370
Mailing Address - Fax:740-886-9374
Practice Address - Street 1:96 TOWNSHIP ROAD 369 STE 101
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-9133
Practice Address - Country:US
Practice Address - Phone:740-886-9370
Practice Address - Fax:740-886-9374
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17624207Y00000X
OH35-07-8877-R207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000222804OtherOH MEDICAID UNISON
P00420122OtherRAILROAD MEDICARE
WV1044883OtherBWC
OH1700821907OtherMOUTAIN STATE BC/BS
OH310917085172OtherOH MEDICAID CARESOURCE
OH0954356Medicaid
WV0100708000Medicaid
WV0100708000Medicaid
OHRO0753727Medicare PIN