Healthcare Provider Details

I. General information

NPI: 1588766125
Provider Name (Legal Business Name): RICHARD M ROACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12109 COUNTY ROAD 103 STE 2
OXFORD FL
34484
US

IV. Provider business mailing address

12109 COUNTY ROAD 103
OXFORD FL
34484-2951
US

V. Phone/Fax

Practice location:
  • Phone: 352-259-4400
  • Fax: 352-787-0307
Mailing address:
  • Phone: 352-205-8981
  • Fax: 352-391-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME117782
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: