Healthcare Provider Details

I. General information

NPI: 1699358549
Provider Name (Legal Business Name): TALAL ROSHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 07/31/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MAPLEMERE RD STE 150
WILLIAMSVILLE NY
14221-3181
US

IV. Provider business mailing address

PO BOX 488
BUFFALO NY
14240-0488
US

V. Phone/Fax

Practice location:
  • Phone: 716-899-4772
  • Fax:
Mailing address:
  • Phone: 716-852-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0073888
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: