Healthcare Provider Details

I. General information

NPI: 1790818169
Provider Name (Legal Business Name): ELISEO ROQUES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PARANA CORNER CARITE 125
SAN JUAN PR
00926-6023
US

IV. Provider business mailing address

138 WINSTON CHURCHILL AVE. MSC 853
SAN JUAN PR
00926-6023
US

V. Phone/Fax

Practice location:
  • Phone: 787-764-3562
  • Fax: 787-753-0996
Mailing address:
  • Phone: 787-764-3562
  • Fax: 787-753-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4783
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: