Healthcare Provider Details

I. General information

NPI: 1174091938
Provider Name (Legal Business Name): NIDSY MEJIA ROQUE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 LYONS TECHNOLOGY CIR STE 190
COCONUT CREEK FL
33073-4322
US

IV. Provider business mailing address

6810 LYONS TECHNOLOGY CIR STE 190
COCONUT CREEK FL
33073-4322
US

V. Phone/Fax

Practice location:
  • Phone: 754-200-1756
  • Fax:
Mailing address:
  • Phone: 754-200-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME163922
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number314151
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberME163922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: