Healthcare Provider Details

I. General information

NPI: 1699705756
Provider Name (Legal Business Name): IRAJ ROSHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 W PANOLA ST
CARTHAGE TX
75633
US

IV. Provider business mailing address

PO BOX 847176
DALLAS TX
75284-7176
US

V. Phone/Fax

Practice location:
  • Phone: 903-694-2871
  • Fax: 903-694-2895
Mailing address:
  • Phone: 903-237-1800
  • Fax: 903-237-1810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberJ8747
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: