Provider Demographics
NPI:1558390484
Name:ROQUE, DIANA (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:ROQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:TRINIDAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10841 PARK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5148
Mailing Address - Country:US
Mailing Address - Phone:813-677-6900
Mailing Address - Fax:813-677-6903
Practice Address - Street 1:10841 PARK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5148
Practice Address - Country:US
Practice Address - Phone:813-677-6900
Practice Address - Fax:813-677-6903
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F14845Medicare UPIN
14538Medicare ID - Type Unspecified