Provider Demographics
NPI:1831162585
Name:ROACH, TERRY (DO)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 PRECINCT LINE RD
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3131
Mailing Address - Country:US
Mailing Address - Phone:817-281-0402
Mailing Address - Fax:817-281-6364
Practice Address - Street 1:1709 PRECINCT LINE RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3131
Practice Address - Country:US
Practice Address - Phone:817-281-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD97667Medicare UPIN
TX8G4793Medicare ID - Type Unspecified