Provider Demographics
NPI:1295997138
Name:ROQUE, DIANA
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:ROQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 CALLE 54 SE
Mailing Address - Street 2:URB. LA RIVIERA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-3141
Mailing Address - Country:US
Mailing Address - Phone:787-774-3766
Mailing Address - Fax:787-883-6124
Practice Address - Street 1:1290 CALLE 54 SE
Practice Address - Street 2:URB. LA RIVIERA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3141
Practice Address - Country:US
Practice Address - Phone:787-774-3766
Practice Address - Fax:787-883-6124
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist