Healthcare Provider Details

I. General information

NPI: 1124169644
Provider Name (Legal Business Name): GIDEON M ROQUIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5205 COVENTRY DR
ERIE PA
16506-6107
US

IV. Provider business mailing address

5205 COVENTRY DR
ERIE PA
16506-6107
US

V. Phone/Fax

Practice location:
  • Phone: 814-835-2362
  • Fax: 814-835-2362
Mailing address:
  • Phone: 814-835-2362
  • Fax: 814-835-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number18457
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: