Provider Demographics
NPI:1235397795
Name:GIDEON M. ROQUIZ
Entity Type:Organization
Organization Name:GIDEON M. ROQUIZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIDEON
Authorized Official - Middle Name:MANIAGO
Authorized Official - Last Name:ROQUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-835-2362
Mailing Address - Street 1:5205 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-6107
Mailing Address - Country:US
Mailing Address - Phone:814-835-2362
Mailing Address - Fax:
Practice Address - Street 1:5205 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-6107
Practice Address - Country:US
Practice Address - Phone:814-835-2362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA027074Medicare PIN