Provider Demographics
NPI:1740592435
Name:ROACH, MICHAEL DEWAYNE (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEWAYNE
Last Name:ROACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N ROUTE B
Mailing Address - Street 2:
Mailing Address - City:HALLSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65255-9266
Mailing Address - Country:US
Mailing Address - Phone:573-696-0500
Mailing Address - Fax:573-696-0509
Practice Address - Street 1:501 N ROUTE B
Practice Address - Street 2:
Practice Address - City:HALLSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65255-9266
Practice Address - Country:US
Practice Address - Phone:573-696-0500
Practice Address - Fax:573-696-0509
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4950207Q00000X
MO2012008079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740592435Medicaid