Provider Demographics
NPI:1437156916
Name:ROQUE, ROGER C (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:C
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:PO BOX 1386
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-1386
Mailing Address - Country:US
Mailing Address - Phone:352-357-1014
Mailing Address - Fax:352-357-3130
Practice Address - Street 1:720 N BAY ST STE 8
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2964
Practice Address - Country:US
Practice Address - Phone:352-357-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31407OtherBCBS
FL31407OtherBCBS
FLG28304Medicare UPIN