MEDICARE: ROGER ROQUE MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1205571015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROGER ROQUE MD LLC

Provider Business Mailing Address
First Line	:	PO BOX 491500
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34749-1500
Country	:	US
Telephone Number	:	352-314-6589
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 S LAKE ST STE 2
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-6059
Country	:	US
Telephone Number	:	352-314-6589
Fax Number	:

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. DAVID P WAGNER
Credential	:
Telephone Number	:	321-204-5222

Provider Enumeration Date	:	05/05/2022
Last Update Date	:	02/03/2023

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