Provider Demographics
NPI:1922007251
Name:ROACH, GARY ARTHUR (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ARTHUR
Last Name:ROACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 E CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2544
Mailing Address - Country:US
Mailing Address - Phone:704-663-3924
Mailing Address - Fax:704-663-7057
Practice Address - Street 1:404 E CENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2544
Practice Address - Country:US
Practice Address - Phone:704-663-3924
Practice Address - Fax:704-663-7057
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2014-11-20
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
NC863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909775Medicaid
NC15906OtherPARTNERS
NC2209268OtherUNITED HEALTHCARE
NC09775OtherBCBS
NC0236390001OtherPALMETTO DMERC
NC15906OtherPARTNERS
NC09775OtherBCBS