Provider Demographics
NPI:1871672766
Name:ROCHE, MARIE-LOURDES (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE-LOURDES
Middle Name:
Last Name:ROCHE
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 1:5610 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3599
Mailing Address - Country:US
Mailing Address - Phone:718-630-7499
Mailing Address - Fax:718-630-6877
Practice Address - Street 1:5610 2ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3599
Practice Address - Country:US
Practice Address - Phone:718-630-7499
Practice Address - Fax:718-630-6877
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01421407Medicaid
NY27H221Medicare ID - Type Unspecified
NY01421407Medicaid