Provider Demographics
NPI:1134254162
Name:ROQUE, JOSE RAMON JR (MD, BCNS, CNC)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAMON
Last Name:ROQUE
Suffix:JR
Gender:M
Credentials:MD, BCNS, CNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111-22 STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047
Mailing Address - Country:US
Mailing Address - Phone:201-866-8121
Mailing Address - Fax:201-866-8004
Practice Address - Street 1:1111 22ND ST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-2003
Practice Address - Country:US
Practice Address - Phone:201-866-8121
Practice Address - Fax:201-866-8004
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3002133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1045653OtherNJ HEALTH
NJ057811Medicare ID - Type Unspecified