Provider Demographics
NPI:1962476200
Name:MYSORE, SATHYENDRA R (MD)
Entity Type:Individual
Prefix:
First Name:SATHYENDRA
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 1:740 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-8601
Mailing Address - Country:US
Mailing Address - Phone:606-877-3931
Mailing Address - Fax:606-877-3978
Practice Address - Street 1:1001 SAINT JOSEPH LN
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8345
Practice Address - Country:US
Practice Address - Phone:606-330-6000
Practice Address - Fax:606-330-7825
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36943207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61-1427889OtherCHA
KY61-1427889OtherTRICARE
KY61-1427889OtherBLUEGRASS FAMILY HEALTH
KY61-1427889OtherUHC
KY61-1427889OtherHUMANA
KY030670000OtherBLACK LUNG
KY50005320OtherPASSPORT HEALTH PLAN
KY64060783Medicaid
KY000000378002OtherANTHEM PROVIDER #
KYC20852OtherCUMBERLAND HEALTHCARE INC
KY0736523Medicare ID - Type Unspecified
KY61-1427889OtherHUMANA