Provider Demographics
NPI:1730252917
Name:ROSCHAK, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:ROSCHAK
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 1:11971 HERITAGE OAK PLACE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2461
Mailing Address - Country:US
Mailing Address - Phone:530-885-0644
Mailing Address - Fax:530-885-6582
Practice Address - Street 1:11971 HERITAGE OAK PLACE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2461
Practice Address - Country:US
Practice Address - Phone:530-885-0644
Practice Address - Fax:530-885-6582
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A243690207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2705416Medicaid
A23948Medicare UPIN
CA00A243690Medicare ID - Type Unspecified