Healthcare Provider Details

I. General information

NPI: 1568576023
Provider Name (Legal Business Name): YVONNE AMANDA ROQUE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6 STREET
BROOKLYN NY
11215
US

IV. Provider business mailing address

P.O. BOX 5450
NEW YORK NY
10087-5450
US

V. Phone/Fax

Practice location:
  • Phone: 718-246-8590
  • Fax: 718-246-8656
Mailing address:
  • Phone: 718-246-8590
  • Fax: 718-246-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA87719
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number251143
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: