Healthcare Provider Details

I. General information

NPI: 1770079006
Provider Name (Legal Business Name): AMY ROACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

8700 BEVERLY BLVD # 8215NT
WEST HOLLYWOOD CA
90048-1804
US

V. Phone/Fax

Practice location:
  • Phone: 323-660-2450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA160884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: