Provider Demographics
NPI:1659231165
Name:NIDO, ROQUE ANTONIO
Entity type:Individual
Prefix:
First Name:ROQUE
Middle Name:ANTONIO
Last Name:NIDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 AV. SAN PATRICIO, COND. EL GENERALIFE
Mailing Address - Street 2:APT. 1604
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LAUREL PLZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-3273
Practice Address - Country:US
Practice Address - Phone:787-798-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6762068390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program