MEDICARE: DR. WILLIAM JOHN MARK ROACH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A50330	CA

General Provider Information

NPI Number	:	1538125497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM JOHN MARK ROACH M.D.

Provider Business Mailing Address
First Line	:	1860 S CENTRAL ST
Second Line	:	SUITE D
City	:	VISALIA
State	:	CA
Zip	:	93277-4418
Country	:	US
Telephone Number	:	559-738-8584
Fax Number	:	559-733-4355

Provider Business Practice Location Address
First Line	:	1860 S CENTRAL ST
Second Line	:	SUITE D
City	:	VISALIA
State	:	CA
Zip	:	93277-4418
Country	:	US
Telephone Number	:	559-738-8584
Fax Number	:	559-733-4355

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	10/01/2008

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