Provider Demographics
NPI:1346290657
Name:MYSORE, MOHAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:R
Last Name:MYSORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 DODGE ST
Mailing Address - Street 2:CHILDRENS HOSPITAL
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4113
Mailing Address - Country:US
Mailing Address - Phone:402-955-5400
Mailing Address - Fax:
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:CHILDRENS HOSPITAL - CRITICAL CARE
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4113
Practice Address - Country:US
Practice Address - Phone:402-955-4226
Practice Address - Fax:402-955-3262
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE205752080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8938OtherMIDLANDS CHOICE
IA0909416Medicaid
NE32104OtherBCBS
NEG25832Medicare UPIN