Provider Demographics
NPI:1851436687
Name:MYSORE R NAGARAJA,M.D.,INC
Entity Type:Organization
Organization Name:MYSORE R NAGARAJA,M.D.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYSORE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NAGARAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-363-3105
Mailing Address - Street 1:17075 DEVONSHIRE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1600
Mailing Address - Country:US
Mailing Address - Phone:818-363-3105
Mailing Address - Fax:818-363-6178
Practice Address - Street 1:17075 DEVONSHIRE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1600
Practice Address - Country:US
Practice Address - Phone:818-363-3105
Practice Address - Fax:818-363-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25685207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A256850Medicaid
CAW5281Medicare ID - Type Unspecified
CA00A256850Medicaid