Provider Demographics
NPI:1164427043
Name:ROQUE, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:ROQUE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:15502 STONEYBROOK WEST PKWY STE 114
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4767
Mailing Address - Country:US
Mailing Address - Phone:407-821-3680
Mailing Address - Fax:407-821-3681
Practice Address - Street 1:15502 STONEYBROOK WEST PKWY STE 114
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4767
Practice Address - Country:US
Practice Address - Phone:407-821-3680
Practice Address - Fax:407-821-3681
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME82763174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH74535Medicare UPIN