Healthcare Provider Details

I. General information

NPI: 1063215937
Provider Name (Legal Business Name): ROSHEN JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COUNTY ROUTE 97
STONY BROOK NY
11790
US

IV. Provider business mailing address

1 HEROES WAY
RIVERHEAD NY
11901-2054
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-8333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberNA
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: