Provider Demographics
NPI:1518989425
Name:MYSORE, MAMATA N (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMATA
Middle Name:N
Last Name:MYSORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6535 N CHARLES ST
Mailing Address - Street 2:STE 300
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5826
Mailing Address - Country:US
Mailing Address - Phone:410-938-5252
Mailing Address - Fax:410-938-5250
Practice Address - Street 1:6535 N CHARLES ST
Practice Address - Street 2:STE 300
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5826
Practice Address - Country:US
Practice Address - Phone:410-938-5252
Practice Address - Fax:410-938-5250
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-01-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD00641032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD135540Y52Medicare PIN