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General NPI Number Information
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NPI Number | 1801773775
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Entity Type | Individual
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Provider Name | PROWSHCHAL MAHATO
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Gender | Female
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Dates
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Enumeration Date | 08/20/2025
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Last Update Date | 08/20/2025
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Provider Practice Location Address
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Address Line | 5838 METRO WAY SW
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City | WYOMING
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State | MI
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Zip | 49519-9619
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Country | US
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Telephone | 616-249-5300
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Fax |
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Provider Business Mailing Address
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Address Line | 2342 WATERTOWN WAY
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-6043
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Country | US
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Telephone |
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901005917
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License Number State | MI
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