Healthcare Provider Details

I. General information

NPI: 1275617987
Provider Name (Legal Business Name): PEDRO J ROQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PEDRO J ROQUE-RODRIGUEZ MD

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/21/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SUFFOLK AVE STE B
BRENTWOOD NY
11717-4311
US

IV. Provider business mailing address

1010 NORTHERN BLVD STE 328
GREAT NECK NY
11021-5329
US

V. Phone/Fax

Practice location:
  • Phone: 631-435-2133
  • Fax: 631-435-4365
Mailing address:
  • Phone: 516-233-2484
  • Fax: 516-304-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number157218
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: