Provider Demographics
NPI:1285842997
Name:SAN DIEGO, MA. OLIVIA ROQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:MA. OLIVIA
Middle Name:ROQUE
Last Name:SAN DIEGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MA. OLIVIA
Other - Middle Name:SANTOS
Other - Last Name:ROQUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1044 N MOZART ST
Mailing Address - Street 2:STE 205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2792
Mailing Address - Country:US
Mailing Address - Phone:773-489-2912
Mailing Address - Fax:773-489-7330
Practice Address - Street 1:1044 N MOZART ST
Practice Address - Street 2:STE 205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2792
Practice Address - Country:US
Practice Address - Phone:773-489-2912
Practice Address - Fax:773-489-7330
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-130487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics