Healthcare Provider Details

I. General information

NPI: 1285842997
Provider Name (Legal Business Name): MA. OLIVIA ROQUE SAN DIEGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MA. OLIVIA SANTOS ROQUE MD

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N MOZART ST STE 205
CHICAGO IL
60622-2792
US

IV. Provider business mailing address

1044 N MOZART ST STE 205
CHICAGO IL
60622-2792
US

V. Phone/Fax

Practice location:
  • Phone: 773-489-2912
  • Fax: 773-489-7330
Mailing address:
  • Phone: 773-489-2912
  • Fax: 773-489-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-130487
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: