Healthcare Provider Details

I. General information

NPI: 1881640639
Provider Name (Legal Business Name): JOHN B ROACH JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17723 HUNTING BOW CIR SUITE 101
LUTZ FL
33558-5371
US

IV. Provider business mailing address

17723 HUNTING BOW CIR SUITE 101
LUTZ FL
33558-5371
US

V. Phone/Fax

Practice location:
  • Phone: 813-528-8744
  • Fax: 813-528-8791
Mailing address:
  • Phone: 813-528-8744
  • Fax: 813-528-8791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS9566
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberOS9566
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberLT06104
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: