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General NPI Number Information
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NPI Number | 1205405875
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Entity Type | Individual
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Provider Name | PRASUN MANDAL DO
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Gender | Male
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Dates
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Enumeration Date | 06/18/2021
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 424 W HIGHWAY 5
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City | WACONIA
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State | MN
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Zip | 55387-1795
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Country | US
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Telephone | 952-442-4461
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Fax |
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Provider Business Mailing Address
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Address Line | 384 BRICKYARD DR
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City | CHASKA
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State | MN
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Zip | 55318-2403
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Country | US
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Telephone | 409-651-6504
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 79925
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 5151015341
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R-12405
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License Number State | IA
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