Provider Demographics
NPI:1457668501
Name:JOHN, ROSHAN (PT)
Entity Type:Individual
Prefix:MR
First Name:ROSHAN
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16095 BIG SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-2023
Mailing Address - Country:US
Mailing Address - Phone:619-719-5565
Mailing Address - Fax:619-719-5502
Practice Address - Street 1:16095 BIG SPRINGS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-2023
Practice Address - Country:US
Practice Address - Phone:619-719-5565
Practice Address - Fax:619-719-5502
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist