Provider Demographics
NPI:1962750778
Name:ROQUE, VICTOR MANUEL (PTA)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:MANUEL
Last Name:ROQUE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 CROOKED CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761
Mailing Address - Country:US
Mailing Address - Phone:407-970-6097
Mailing Address - Fax:
Practice Address - Street 1:1200 LEXINGTON GREEN LANE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771
Practice Address - Country:US
Practice Address - Phone:407-688-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23530225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686675Medicare PIN