Basic Information
| Provider Information | |||||||||
| NPI: | 1780611533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROCHA | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22405 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631260405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888438475 | ||||||||
| FaxNumber: | 8444103800 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 S HIGUERA ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055416033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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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 | 207ZP0105X | G76988 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | G76988 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00G769880 | 05 | CA | MEDICAID | GR0058760 | 05 | CA | MEDICAID |