Provider Demographics
NPI:1912993460
Name:ROCHE, TIMOTHY S (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:ROCHE
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-2209
Practice Address - Street 1:142 CLINTON ST
Practice Address - Street 2:CLINTON STREET FAMILY CARE CENTER
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2212
Practice Address - Country:US
Practice Address - Phone:607-762-2660
Practice Address - Fax:607-762-2055
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02282011Medicaid
H64728Medicare UPIN
NYDD1582Medicare PIN