Healthcare Provider Details

I. General information

NPI: 1710982020
Provider Name (Legal Business Name): ROMEO V. ROQUE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 WESTERN AVE SUITE 102
ALBANY NY
12203-3539
US

IV. Provider business mailing address

1450 WESTERN AVE SUITE 102
ALBANY NY
12203-3539
US

V. Phone/Fax

Practice location:
  • Phone: 518-463-0050
  • Fax: 518-207-2973
Mailing address:
  • Phone: 518-463-0050
  • Fax: 518-207-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number113746-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: