Provider Demographics
NPI:1750339917
Name:ROQUE, TARA M (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:ROQUE
Suffix:
Gender:F
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:PO BOX 791372
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1372
Mailing Address - Country:US
Mailing Address - Phone:301-608-8375
Mailing Address - Fax:301-608-3979
Practice Address - Street 1:8600 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1422
Practice Address - Country:US
Practice Address - Phone:301-896-3100
Practice Address - Fax:301-896-2393
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061569207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC040143800Medicaid
MD64460401OtherCAREFIRST BCBS
MD415096100Medicaid
DC19460029OtherCAREFIRST BCBS
MD405306100Medicaid
MD405306100Medicaid
DC040143800Medicaid
DCG02860P07Medicare PIN
MD014399I28Medicare ID - Type Unspecified