Provider Demographics
NPI:1215940887
Name:ROACH, BRIAN CHARLES (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:577 AIRPORT BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-2020
Mailing Address - Country:US
Mailing Address - Phone:650-240-8040
Mailing Address - Fax:650-348-9060
Practice Address - Street 1:1720 EL CAMINO REAL
Practice Address - Street 2:SUITE 160
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3224
Practice Address - Country:US
Practice Address - Phone:650-259-9480
Practice Address - Fax:650-259-1428
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG 035559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG035559OtherMEDICAL LICENSE
CAG035559OtherMEDICAL LICENSE