Healthcare Provider Details

I. General information

NPI: 1588869994
Provider Name (Legal Business Name): DANA MARIE ROQUE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST SUITE S3AX-31
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

250 W PRATT ST SUITE 880
BALTIMORE MD
21201-2423
US

V. Phone/Fax

Practice location:
  • Phone: 667-214-1302
  • Fax: 410-328-3379
Mailing address:
  • Phone: 667-214-1302
  • Fax: 410-328-3379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMT 191169
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number049475
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberD0078133
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: