Provider Demographics
NPI:1760467468
Name:ROACH, PAUL JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEFFREY
Last Name:ROACH
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 1:4616 W HOWARD LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6300
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:512-324-8906
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:512-324-3440
Practice Address - Fax:512-406-6513
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1370207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8ET553OtherBCBS
TX137563614Medicaid
TX137563617Medicaid
TX137563615Medicaid
TX137563616Medicaid
TX8CN870OtherBCBS
TXP00837339OtherRAILROAD MEDICARE
TX328441YL9XMedicare PIN
TX8CN870OtherBCBS
TX137563617Medicaid
TX8ET553OtherBCBS
TXTXB117170Medicare PIN