Provider Demographics
NPI:1073697082
Name:MAITRI, MYSORE VIJAYENDRA (MD)
Entity Type:Individual
Prefix:MS
First Name:MYSORE
Middle Name:VIJAYENDRA
Last Name:MAITRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22505 LANDMARK CT STE 210
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6502
Mailing Address - Country:US
Mailing Address - Phone:571-612-6600
Mailing Address - Fax:571-612-6601
Practice Address - Street 1:22505 LANDMARK CT STE 210
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148-6502
Practice Address - Country:US
Practice Address - Phone:571-612-6600
Practice Address - Fax:571-612-6601
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223454207R00000X
VA0101250502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02217265Medicaid
NYH55333Medicare UPIN
NY0105NLMedicare ID - Type Unspecified