Provider Demographics
NPI:1932397189
Name:ROQUE, RONALDO VIOLETA (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALDO
Middle Name:VIOLETA
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 1:1760 TERMINO AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2169
Mailing Address - Country:US
Mailing Address - Phone:562-494-8512
Mailing Address - Fax:562-494-8530
Practice Address - Street 1:1760 TERMINO AVE STE 104
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2169
Practice Address - Country:US
Practice Address - Phone:562-494-8512
Practice Address - Fax:562-494-8530
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A748230Medicaid
CA00A748230Medicaid
CAA74823Medicare PIN