Provider Demographics
NPI:1548242324
Name:ROQUE, JORGE ALEJANDRO (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ALEJANDRO
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 1:2802 SANTA OLIVIA
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-7615
Mailing Address - Country:US
Mailing Address - Phone:956-584-8746
Mailing Address - Fax:
Practice Address - Street 1:900 S BRYAN RD
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6613
Practice Address - Country:US
Practice Address - Phone:956-580-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3841207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R0701OtherBCBS
TX8F1320Medicare PIN
TX00971HMedicare PIN
TXP00178871Medicare PIN
TX8R0701OtherBCBS
TX8C6191Medicare PIN