Provider Demographics
NPI:1457570459
Name:ROQUE-PONTON MEDICAL GROUP, S.C.
Entity Type:Organization
Organization Name:ROQUE-PONTON MEDICAL GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-271-3344
Mailing Address - Street 1:3861 W PRATT AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2544
Mailing Address - Country:US
Mailing Address - Phone:773-271-3344
Mailing Address - Fax:773-271-4540
Practice Address - Street 1:2740 W FOSTER AVE
Practice Address - Street 2:SUITE 313
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3500
Practice Address - Country:US
Practice Address - Phone:773-271-4455
Practice Address - Fax:773-271-4540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38340020OtherFAMILY PRACTICE
AK5348OtherFAMILY PRACTICE
G35633Medicare UPIN
IL213165Medicare ID - Type Unspecified