Healthcare Provider Details

I. General information

NPI: 1134254162
Provider Name (Legal Business Name): JOSE RAMON ROQUE JR. MD, BCNS, CNC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 22ND ST
NORTH BERGEN NJ
07047-2003
US

IV. Provider business mailing address

1111-22 STREET
NORTH BERGEN NJ
07047
US

V. Phone/Fax

Practice location:
  • Phone: 201-866-8121
  • Fax: 201-866-8004
Mailing address:
  • Phone: 201-866-8121
  • Fax: 201-866-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number3002
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: