Provider Demographics
NPI:1932210747
Name:ROACH, CHRISTOPHER J (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:ROACH
Suffix:
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:PO BOX 3100
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-3100
Mailing Address - Country:US
Mailing Address - Phone:970-382-8800
Mailing Address - Fax:970-382-0122
Practice Address - Street 1:1 MERCADO ST # 105
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7300
Practice Address - Country:US
Practice Address - Phone:970-382-8800
Practice Address - Fax:970-382-0122
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO34396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC196918Medicare PIN
COC21115Medicare UPIN