Healthcare Provider Details

I. General information

NPI: 1376505834
Provider Name (Legal Business Name): GEORGE ROQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 08/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 S WICKHAM RD
WEST MELBOURNE FL
32904-3540
US

IV. Provider business mailing address

1541 S WICKHAM RD
WEST MELBOURNE FL
32904-3540
US

V. Phone/Fax

Practice location:
  • Phone: 321-726-6331
  • Fax: 321-726-6371
Mailing address:
  • Phone: 321-254-1220
  • Fax: 321-254-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME88828
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: