Provider Demographics
NPI:1881640639
Name:ROACH, JOHN B JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:ROACH
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17723 HUNTING BOW CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5371
Mailing Address - Country:US
Mailing Address - Phone:813-528-8744
Mailing Address - Fax:813-528-8791
Practice Address - Street 1:17723 HUNTING BOW CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5371
Practice Address - Country:US
Practice Address - Phone:813-528-8744
Practice Address - Fax:813-528-8791
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS9566208600000X, 2086S0122X
MELT06104174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEI27716Medicare UPIN