Provider Demographics
NPI:1679692560
Name:ROQUE NAZARIO, ELAINE (MD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:ROQUE NAZARIO
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:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3010 FARROW RD
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7607
Practice Address - Country:US
Practice Address - Phone:803-434-1210
Practice Address - Fax:803-434-1212
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC57-0359174OtherTAX ID
SCAA39575770Medicare PIN