Basic Information
| Provider Information | |||||||||
| NPI: | 1003802174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCHE | ||||||||
| FirstName: | STEVE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12850 HILLCREST RD | ||||||||
| Address2: | SUITE F-206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752301529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724048253 | ||||||||
| FaxNumber: | 9727010874 | ||||||||
| Practice Location | |||||||||
| Address1: | 12850 HILLCREST RD | ||||||||
| Address2: | SUITE F-206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752301529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724048253 | ||||||||
| FaxNumber: | 9727010874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 09/30/2010 | ||||||||
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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 | 2084P0800X | G6086 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 099855101 | 05 | TX | MEDICAID |