Basic Information
| Provider Information | |||||||||
| NPI: | 1760467468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JEFFREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4616 W HOWARD LN | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787286300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
| FaxNumber: | 5123248906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W 38TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243440 | ||||||||
| FaxNumber: | 5124066513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | J1370 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | J1370 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 8ET553 | 01 | TX | BCBS | OTHER | 137563614 | 05 | TX | MEDICAID | 137563617 | 05 | TX | MEDICAID | 137563615 | 05 | TX | MEDICAID | 137563616 | 05 | TX | MEDICAID | 8CN870 | 01 | TX | BCBS | OTHER | P00837339 | 01 | TX | RAILROAD MEDICARE | OTHER |