Provider Demographics
NPI:1821584780
Name:MYSORE, SUKRITA SHESHU (MD)
Entity Type:Individual
Prefix:
First Name:SUKRITA
Middle Name:SHESHU
Last Name:MYSORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUKRITA
Other - Middle Name:
Other - Last Name:SHESHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:224 CHURCH ST APT 403
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4567
Mailing Address - Country:US
Mailing Address - Phone:704-778-6403
Mailing Address - Fax:
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD91596208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist