Healthcare Provider Details

I. General information

NPI: 1164427043
Provider Name (Legal Business Name): MARK D ROQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 HARRISON BRIDGE RD
SIMPSONVILLE SC
29680-7004
US

IV. Provider business mailing address

559 HARRISON BRIDGE RD
SIMPSONVILLE SC
29680-7004
US

V. Phone/Fax

Practice location:
  • Phone: 864-272-0388
  • Fax:
Mailing address:
  • Phone: 864-272-0388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21147
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: