Provider Demographics
NPI:1780686014
Name:ROACH, KENNETH WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILLIAM
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 1:605 ATTAIN ST
Mailing Address - Street 2:# 101
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1972
Mailing Address - Country:US
Mailing Address - Phone:919-567-3709
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:SUITE #204
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2056
Practice Address - Country:US
Practice Address - Phone:919-567-3709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300401207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134UYMedicaid
H66951Medicare UPIN
NC89134UYMedicaid