Provider Demographics
NPI:1477758357
Name:DIAZ WONG, ROQUE ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ROQUE
Middle Name:ALBERTO
Last Name:DIAZ WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7142 SAN PEDRO AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6256
Mailing Address - Country:US
Mailing Address - Phone:210-661-5622
Mailing Address - Fax:210-798-6811
Practice Address - Street 1:4330 MEDICAL DR STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3342
Practice Address - Country:US
Practice Address - Phone:210-692-7228
Practice Address - Fax:210-692-9671
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301089787207R00000X
TXP5965207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX324927801Medicaid
TX324927801Medicaid