Provider Demographics
NPI:1558385914
Name:RON V. ROQUE, M.D., INC.
Entity Type:Organization
Organization Name:RON V. ROQUE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANALDO
Authorized Official - Middle Name:V
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-494-8512
Mailing Address - Street 1:1760 TERMINO AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2169
Mailing Address - Country:US
Mailing Address - Phone:562-494-8512
Mailing Address - Fax:562-494-8530
Practice Address - Street 1:1760 TERMINO AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2169
Practice Address - Country:US
Practice Address - Phone:562-494-8512
Practice Address - Fax:562-494-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A748230Medicaid
CA00A748230Medicaid
CAH51778Medicare UPIN