Healthcare Provider Details

I. General information

NPI: 1457570459
Provider Name (Legal Business Name): ROQUE-PONTON MEDICAL GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE SUITE 313
CHICAGO IL
60625-3500
US

IV. Provider business mailing address

3861 W PRATT AVE
LINCOLNWOOD IL
60712-2544
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-4455
  • Fax: 773-271-4540
Mailing address:
  • Phone: 773-271-3344
  • Fax: 773-271-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID LOPEZ ROQUE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-271-3344