Provider Demographics
NPI:1922005974
Name:ROACH, M CAREY III (MD)
Entity Type:Individual
Prefix:
First Name:M CAREY
Middle Name:
Last Name:ROACH
Suffix:III
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 1:11415 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211
Mailing Address - Country:US
Mailing Address - Phone:501-224-5220
Mailing Address - Fax:501-228-9828
Practice Address - Street 1:11415 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211
Practice Address - Country:US
Practice Address - Phone:501-224-5220
Practice Address - Fax:501-228-9828
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2521207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140058001Medicaid
H19803Medicare UPIN
5L426Medicare ID - Type Unspecified