Provider Demographics
NPI:1770915589
Name:ROSHAN, SYEDA (DPM)
Entity type:Individual
Prefix:
First Name:SYEDA
Middle Name:
Last Name:ROSHAN
Suffix:
Gender:F
Credentials:DPM
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 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:414-253-8330
Mailing Address - Fax:414-244-9957
Practice Address - Street 1:4282 E ROCKTON RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073
Practice Address - Country:US
Practice Address - Phone:779-696-9000
Practice Address - Fax:779-696-8170
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005560213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400179242Medicare PIN