MEDICARE: KENNETH WILLIAM ROACH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	200300401	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780686014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WILLIAM ROACH M.D.

Provider Business Mailing Address
First Line	:	605 ATTAIN ST
Second Line	:	# 101
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-1972
Country	:	US
Telephone Number	:	919-567-3709
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 N MAIN ST
Second Line	:	SUITE #204
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-2056
Country	:	US
Telephone Number	:	919-567-3709
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	02/06/2018

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