Provider Demographics
NPI:1396847448
Name:ROQUE, JOEY EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOEY
Middle Name:EDWARD
Last Name:ROQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-0847
Mailing Address - Country:US
Mailing Address - Phone:843-652-1415
Mailing Address - Fax:843-366-4387
Practice Address - Street 1:4070 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5033
Practice Address - Country:US
Practice Address - Phone:843-652-1415
Practice Address - Fax:843-366-4387
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC81712208100000X
TN41492208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC81712OtherSTATE OF SOUTH CAROLINA MEDICAL LICENSE