Healthcare Provider Details

I. General information

NPI: 1306588199
Provider Name (Legal Business Name): RONALD REGIN ROQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 W HERNDON AVE STE 107
FRESNO CA
93722-8401
US

IV. Provider business mailing address

2458 GLEN HAIG WAY
SAN JOSE CA
95148-4113
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-6310
  • Fax: 559-450-6311
Mailing address:
  • Phone: 408-893-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA197809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: