Provider Demographics
NPI:1922093178
Name:OLOFSSON, ROSANNA T (DO)
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:T
Last Name:OLOFSSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BETHANY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4908
Mailing Address - Country:US
Mailing Address - Phone:815-758-8621
Mailing Address - Fax:815-758-5838
Practice Address - Street 1:625 BETHANY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4908
Practice Address - Country:US
Practice Address - Phone:815-758-8621
Practice Address - Fax:815-758-5838
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG36498Medicare UPIN
IL205297Medicare PIN