Healthcare Provider Details

I. General information

NPI: 1164427043
Provider Name (Legal Business Name): MARK D ROQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15502 STONEYBROOK WEST PKWY STE 114
WINTER GARDEN FL
34787-4767
US

IV. Provider business mailing address

15502 STONEYBROOK WEST PKWY STE 114
WINTER GARDEN FL
34787-4767
US

V. Phone/Fax

Practice location:
  • Phone: 407-821-3680
  • Fax: 407-821-3681
Mailing address:
  • Phone: 407-821-3680
  • Fax: 407-821-3681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME82763
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME82763
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: