Healthcare Provider Details

I. General information

NPI: 1902840416
Provider Name (Legal Business Name): CLEMENTE T ROQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY HOSPITAL
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-6919
  • Fax:
Mailing address:
  • Phone: 631-444-6919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number158433
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: