Provider Demographics
NPI:1063436897
Name:ROCHE, GREGORY C (DO)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:C
Last Name:ROCHE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:50 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2217
Mailing Address - Country:US
Mailing Address - Phone:248-338-5516
Mailing Address - Fax:248-338-5547
Practice Address - Street 1:43494 S. WOODWARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302
Practice Address - Country:US
Practice Address - Phone:248-338-1110
Practice Address - Fax:248-338-4590
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007111207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA73602Medicare UPIN
MIOF36228025Medicare ID - Type Unspecified