Provider Demographics
NPI:1275617987
Name:ROQUE, PEDRO J (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:J
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 1:5 WICKS ROAD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-3508
Mailing Address - Country:US
Mailing Address - Phone:631-435-2133
Mailing Address - Fax:631-435-4365
Practice Address - Street 1:5 WICKS ROAD
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-3508
Practice Address - Country:US
Practice Address - Phone:631-435-2133
Practice Address - Fax:631-435-4365
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00891974Medicaid
43D491Medicare ID - Type Unspecified
NY00891974Medicaid