Healthcare Provider Details

I. General information

NPI: 1609050293
Provider Name (Legal Business Name): CYNTHIA CECILIA ROQUE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9145 NARCOOSSEE RD STE 103
ORLANDO FL
32827-5768
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 407-243-2040
  • Fax: 407-243-2043
Mailing address:
  • Phone: 904-697-4100
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number048900
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME134151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: