Provider Demographics
NPI:1205405875
Name:MANDAL, PRASUN (DO)
Entity type:Individual
Prefix:
First Name:PRASUN
Middle Name:
Last Name:MANDAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 BRICKYARD DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2403
Mailing Address - Country:US
Mailing Address - Phone:409-651-6504
Mailing Address - Fax:
Practice Address - Street 1:424 W HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1795
Practice Address - Country:US
Practice Address - Phone:952-442-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79925207Q00000X
MI5151015341208600000X
IAR-12405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery