Provider Demographics
NPI:1265875249
Name:ROQUE-LICHTIG, SHELLEY G (MD)
Entity type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:G
Last Name:ROQUE-LICHTIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 BURNS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4328
Mailing Address - Country:US
Mailing Address - Phone:561-944-5534
Mailing Address - Fax:561-461-6121
Practice Address - Street 1:1094 MILITARY TRL
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7021
Practice Address - Country:US
Practice Address - Phone:561-622-6111
Practice Address - Fax:855-215-9930
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012929000Medicaid
FL14W3FOtherBCBS
FL1614472OtherCIGNA