Provider Demographics
NPI:1629631395
Name:MYSORE, POOJA (MD)
Entity type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:MYSORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BRAYTON CT S
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4627
Mailing Address - Country:US
Mailing Address - Phone:631-833-8616
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE BLDG 3
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-251-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100905207P00000X, 2086S0102X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care