MEDICARE: ROGER C ROQUE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME70970	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31407	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1437156916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER C ROQUE MD

Provider Business Mailing Address
First Line	:	PO BOX 1386
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32727-1386
Country	:	US
Telephone Number	:	352-357-1014
Fax Number	:	352-357-3130

Provider Business Practice Location Address
First Line	:	720 N BAY ST STE 8
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32726-2964
Country	:	US
Telephone Number	:	352-357-1014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	08/25/2011

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