Provider Demographics
NPI:1225573579
Name:PANCHAL, NAIYA (OD)
Entity Type:Individual
Prefix:DR
First Name:NAIYA
Middle Name:
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8526
Mailing Address - Country:US
Mailing Address - Phone:517-337-0316
Mailing Address - Fax:517-622-1205
Practice Address - Street 1:830 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068
Practice Address - Country:US
Practice Address - Phone:269-781-9822
Practice Address - Fax:269-781-3622
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011075152W00000X
MI4901005026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225573579Medicaid