Provider Demographics
NPI:1922468677
Name:ROACH, REX DANIEL III (MD)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:DANIEL
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 1:6554 LUBARRETT WAY
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3825
Mailing Address - Country:US
Mailing Address - Phone:251-533-3221
Mailing Address - Fax:
Practice Address - Street 1:6554 LUBARRETT WAY
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-3825
Practice Address - Country:US
Practice Address - Phone:251-533-3221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21974207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology