Healthcare Provider Details

I. General information

NPI: 1417970583
Provider Name (Legal Business Name): MICHAEL O ROACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15625 IMPERIAL HWY
LA MIRADA CA
90638-1301
US

IV. Provider business mailing address

15625 IMPERIAL HWY
LA MIRADA CA
90638-1627
US

V. Phone/Fax

Practice location:
  • Phone: 562-902-3000
  • Fax: 562-902-9563
Mailing address:
  • Phone: 562-902-3000
  • Fax: 562-902-9563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberG32190
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG32190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: