Provider Demographics
NPI:1295757540
Name:ROACH, LOUIS C (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:C
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:2026 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5822
Practice Address - Country:US
Practice Address - Phone:903-541-4500
Practice Address - Fax:903-589-1594
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2762208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M6644OtherBCBS-JACKSONVILLE
TX034106702Medicaid
TX8M6644OtherBCBS-JACKSONVILLE
TX8G9423Medicare PIN