Healthcare Provider Details

I. General information

NPI: 1730272097
Provider Name (Legal Business Name): JOSE M. ROQUE, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 08/22/2020
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: DR. JOSE M. ROQUE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-937-9400