Healthcare Provider Details

I. General information

NPI: 1598740466
Provider Name (Legal Business Name): GABRIEL BOLADELE ROSANWO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 4470
SOUTH BEND IN
46601-1168
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1405
  • Fax: 574-647-3970
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01080180A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01080180A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: