Provider Demographics
NPI:1760691810
Name:ROQUE, RICHARD A (IDC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:ROQUE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NMCB 7 MEDICAL DEPARTMENT
Mailing Address - Street 2:UNIT 60252
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34099
Mailing Address - Country:US
Mailing Address - Phone:228-223-5879
Mailing Address - Fax:
Practice Address - Street 1:5503 MARVIN SHIELDS BLVD
Practice Address - Street 2:SEA BEE BASE CLINIC
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-871-2810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman