Healthcare Provider Details

I. General information

NPI: 1265875249
Provider Name (Legal Business Name): SHELLEY G ROQUE-LICHTIG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1094 MILITARY TRL
JUPITER FL
33458-7021
US

IV. Provider business mailing address

3385 BURNS RD STE 101
PALM BEACH GARDENS FL
33410-4328
US

V. Phone/Fax

Practice location:
  • Phone: 561-622-6111
  • Fax: 855-215-9930
Mailing address:
  • Phone: 561-944-5534
  • Fax: 561-461-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME115186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: