Provider Demographics
NPI:1770502940
Name:ROQUE, DAVID LOPEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LOPEZ
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 1:3861 W PRATT
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712
Mailing Address - Country:US
Mailing Address - Phone:773-271-3344
Mailing Address - Fax:773-271-4540
Practice Address - Street 1:2740 W FOSTER
Practice Address - Street 2:SUITE 313
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-271-3344
Practice Address - Fax:773-271-4540
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094226207Q00000X
WI38340020207Q00000X
AK5348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094226Medicaid
G35633Medicare UPIN