Provider Demographics
NPI:1982052080
Name:ROACH, WILLIAM BRADLEY (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADLEY
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 1:1559 ALA AMOAMO ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1710
Mailing Address - Country:US
Mailing Address - Phone:617-721-2434
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:888-683-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101264620207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program