Basic Information
| Provider Information | |||||||||
| NPI: | 1518453422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOGTE | ||||||||
| FirstName: | PRIYANKA | ||||||||
| MiddleName: | VISHWANATH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 N. EAST AVE. | ||||||||
| Address2: | 2ND FLOOR ANDERSON BUILDING | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172057147 | ||||||||
| FaxNumber: | 5172057050 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N. EAST AVE. | ||||||||
| Address2: | 2ND FLOOR ANDERSON BUILDING | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172057147 | ||||||||
| FaxNumber: | 5172057050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2018 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301115386 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.