Provider Demographics
NPI:1376505834
Name:ROQUE, GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
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 1:1541 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3540
Mailing Address - Country:US
Mailing Address - Phone:321-254-1220
Mailing Address - Fax:321-254-1250
Practice Address - Street 1:1541 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3540
Practice Address - Country:US
Practice Address - Phone:321-726-6331
Practice Address - Fax:321-726-6371
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00196213OtherRAILROAD MEDICARE #
10024OtherFLORIDANCARE PROVIDER #
246370OtherWELLCARE MCAID PROVIDER #
9303692OtherCIGNA PROVIDER #
201388186OtherUNITED HEALTHCARE #
201388186OtherHEALTH FIRST PROVIDER #
201388186OtherHUMANA PROVIDER #
FL6691200001OtherMEDICARE DME
7274610OtherAETNA PROVIDER #
201388186OtherTRICARE PROVIDER #
FL270958900Medicaid
5585831OtherCCN NETWORK PROVIDER #
37972OtherBCBS PROVIDER #
9362860OtherPHCS PROVIDER #
1809978OtherFIRST HEALTH PROVIDER#
201388186OtherHUMANA PROVIDER #
9362860OtherPHCS PROVIDER #