Provider Demographics
NPI:1609827161
Name:COQUIS, ROBERTO P SR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:P
Last Name:COQUIS
Suffix:SR
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 1:2161 E COMMERCIAL BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3810
Mailing Address - Country:US
Mailing Address - Phone:954-491-5187
Mailing Address - Fax:954-491-5217
Practice Address - Street 1:2161 E COMMERCIAL BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3810
Practice Address - Country:US
Practice Address - Phone:954-491-5187
Practice Address - Fax:954-491-5217
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027643174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057490200Medicaid
FL057490200Medicaid
FL93310Medicare ID - Type Unspecified