Healthcare Provider Details

I. General information

NPI: 1770528226
Provider Name (Legal Business Name): KATHERINE ROQUE M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9375 SAN FERNANDO RD
SUN VALLEY CA
91352-1418
US

IV. Provider business mailing address

9375 SAN FERNANDO RD
SUN VALLEY CA
91352-1418
US

V. Phone/Fax

Practice location:
  • Phone: 818-768-3000
  • Fax: 818-504-4690
Mailing address:
  • Phone: 818-768-3000
  • Fax: 818-504-4690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: