Healthcare Provider Details

I. General information

NPI: 1154362010
Provider Name (Legal Business Name): JOSE M. ROQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S MAIN ST SUITE 215
ORANGE CA
92868-3851
US

IV. Provider business mailing address

230 S MAIN ST SUITE 215
ORANGE CA
92868-3851
US

V. Phone/Fax

Practice location:
  • Phone: 714-937-9400
  • Fax: 714-937-9404
Mailing address:
  • Phone: 714-937-9400
  • Fax: 714-937-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG71898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: