Provider Demographics
NPI:1649274390
Name:ROACH, DOROTHY J (MD)
Entity type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:J
Last Name:ROACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 VISION PARK BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3002
Mailing Address - Country:US
Mailing Address - Phone:281-444-4784
Mailing Address - Fax:281-444-0429
Practice Address - Street 1:111 VISION PARK BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3002
Practice Address - Country:US
Practice Address - Phone:281-444-4784
Practice Address - Fax:281-444-0429
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2015-04-02
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
TXF7104207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D77SMedicare PIN
TXE-30967Medicare UPIN