Provider Demographics
NPI:1275617987
Name:ROQUE, PEDRO J (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:J
Last Name:ROQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PEDRO
Other - Middle Name:J
Other - Last Name:ROQUE-RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1010 NORTHERN BLVD STE 328
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5329
Mailing Address - Country:US
Mailing Address - Phone:516-233-2484
Mailing Address - Fax:516-304-5850
Practice Address - Street 1:600 SUFFOLK AVE STE B
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4311
Practice Address - Country:US
Practice Address - Phone:631-435-2133
Practice Address - Fax:631-435-4365
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00891974Medicaid
43D491Medicare ID - Type Unspecified
NY00891974Medicaid