Healthcare Provider Details

I. General information

NPI: 1679882005
Provider Name (Legal Business Name): BHAGYA MYSORE VENKATESH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 EAST MICHIGAN AVENUE
LANSING MI
48910
US

IV. Provider business mailing address

901 EAST MICHIGAN AVENUE
LANSING MI
48910
US

V. Phone/Fax

Practice location:
  • Phone: 517-485-1153
  • Fax:
Mailing address:
  • Phone: 517-485-1153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301097216
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: