Healthcare Provider Details

I. General information

NPI: 1962435586
Provider Name (Legal Business Name): MARTIN ROCHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N HWY 173
LAKE ARROWHEAD CA
92321
US

IV. Provider business mailing address

PO BOX 716
CEDAR GLEN CA
92321-0716
US

V. Phone/Fax

Practice location:
  • Phone: 909-336-3670
  • Fax: 909-336-3674
Mailing address:
  • Phone: 909-336-3670
  • Fax: 909-336-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA54355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: