Provider Demographics
NPI:1043885130
Name:ROSHAN, FNU (MD)
Entity type:Individual
Prefix:
First Name:FNU
Middle Name:
Last Name:ROSHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4804
Mailing Address - Country:US
Mailing Address - Phone:814-889-2223
Mailing Address - Fax:
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-889-2223
Practice Address - Fax:814-889-7808
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2024-05-30
Deactivation Date:2022-11-14
Deactivation Code:
Reactivation Date:2023-10-17
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
PAMD483288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program