Provider Demographics
NPI:1053309393
Name:ROECKER, KURT M (DO)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:M
Last Name:ROECKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7581 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7581 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9624
Practice Address - Country:US
Practice Address - Phone:734-856-6360
Practice Address - Fax:734-856-6364
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3401539207Q00000X
MI5101013387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4506636Medicaid
MI0855811754OtherBCBS OF MICHIGAN
MION71250Medicare ID - Type Unspecified
MI4506636Medicaid