Healthcare Provider Details

I. General information

NPI: 1437156916
Provider Name (Legal Business Name): ROGER C ROQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N BAY ST STE 8
EUSTIS FL
32726-2964
US

IV. Provider business mailing address

PO BOX 1386
EUSTIS FL
32727-1386
US

V. Phone/Fax

Practice location:
  • Phone: 352-357-1014
  • Fax:
Mailing address:
  • Phone: 352-357-1014
  • Fax: 352-357-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME70970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: