Healthcare Provider Details

I. General information

NPI: 1225573579
Provider Name (Legal Business Name): NAIYA PANCHAL O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2016
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W MICHIGAN AVE
MARSHALL MI
49068
US

IV. Provider business mailing address

702 W LAKE LANSING RD
EAST LANSING MI
48823-8526
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-9822
  • Fax: 269-781-3622
Mailing address:
  • Phone: 517-337-0316
  • Fax: 517-622-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011075
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005026
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: