Provider Demographics
NPI:1134141096
Name:ROQUE, ELMER DEJESUS (MD)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:DEJESUS
Last Name:ROQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 ST LUKES DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7102
Mailing Address - Country:US
Mailing Address - Phone:334-356-1411
Mailing Address - Fax:334-356-1578
Practice Address - Street 1:337 ST LUKES DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7102
Practice Address - Country:US
Practice Address - Phone:334-356-1411
Practice Address - Fax:334-356-1578
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00022416207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL392055922Medicaid
AL630903054Medicaid
AL630901054Medicaid
AL009910176Medicaid
AL51060553OtherBCBS
AL6309000054Medicaid
AL515165531OtherBCBS
AL51516953OtherBCBS
AL630902054Medicaid
ALP00040942OtherRAILROAD
AL630903054Medicaid
AL392055922Medicaid
ALH33629Medicare UPIN