Provider Demographics
NPI:1922015049
Name:GARY A. ROACH, O.D., P.A.
Entity Type:Organization
Organization Name:GARY A. ROACH, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-663-3924
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018TFOtherBCBS
NCDG1209OtherMEDICARE RAILROAD
NC2209268OtherUNITED HEALTHCARE
NC15906OtherPARTNERS MEDICARE CHOICE
NC5906031Medicaid
NC0236390001Medicare NSC
NC2209268OtherUNITED HEALTHCARE
NC246201Medicare PIN