Provider Demographics
NPI:1477058949
Name:ROSLAWSKI, IAN (DO)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:ROSLAWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42D MEDICAL GROUP, 300 S. TWINING ST BLDG 760
Mailing Address - Street 2:
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112
Mailing Address - Country:US
Mailing Address - Phone:334-953-3368
Mailing Address - Fax:334-953-8607
Practice Address - Street 1:42D MEDICAL GROUP, 300 S. TWINING ST BLDG 760
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-3368
Practice Address - Fax:334-953-8607
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072855207Q00000X
390200000X
MO2020011225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program