Provider Demographics
NPI:1861470239
Name:ROCA, THERESA PRYOR (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:PRYOR
Last Name:ROCA
Suffix:
Gender:F
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504
Practice Address - Country:US
Practice Address - Phone:850-505-4700
Practice Address - Fax:850-505-4711
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME920342080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117936Medicaid
AL009934152Medicaid
FL273251300Medicaid
AL009934152Medicaid
16983ZMedicare PIN