Provider Demographics
NPI:1174091938
Name:MEJIA ROQUE, NIDSY (MD)
Entity type:Individual
Prefix:
First Name:NIDSY
Middle Name:
Last Name:MEJIA ROQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 LYONS TECHNOLOGY CIR STE 190
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4322
Mailing Address - Country:US
Mailing Address - Phone:754-200-1756
Mailing Address - Fax:
Practice Address - Street 1:6810 LYONS TECHNOLOGY CIR STE 190
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4322
Practice Address - Country:US
Practice Address - Phone:754-200-1756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME163922208000000X, 2080P0006X
NY314151208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty