Provider Demographics
NPI:1588869994
Name:ROQUE, DANA MARIE (MD)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:ROQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:250 W PRATT ST
Mailing Address - Street 2:SUITE 880
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-2423
Mailing Address - Country:US
Mailing Address - Phone:667-214-1302
Mailing Address - Fax:410-328-3379
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:SUITE S3AX-31
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:667-214-1302
Practice Address - Fax:410-328-3379
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT 191169207V00000X
CT049475207VX0201X
MDD0078133207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD324852600Medicaid
MD324852600Medicaid