Healthcare Provider Details

I. General information

NPI: 1760691810
Provider Name (Legal Business Name): RICHARD A ROQUE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5503 MARVIN SHIELDS BLVD SEA BEE BASE CLINIC
GULFPORT MS
39501
US

IV. Provider business mailing address

NMCB 7 MEDICAL DEPARTMENT UNIT 60252
FPO AA
34099
US

V. Phone/Fax

Practice location:
  • Phone: 228-871-2810
  • Fax:
Mailing address:
  • Phone: 228-223-5879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: