Healthcare Provider Details

I. General information

NPI: 1427410109
Provider Name (Legal Business Name): MANU MYSORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

110 S PACA ST FL 7
BALTIMORE MD
21201-1642
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-7877
  • Fax: 410-328-1048
Mailing address:
  • Phone: 410-328-7877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0089398
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberD89398
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: