Healthcare Provider Details

I. General information

NPI: 1629631395
Provider Name (Legal Business Name): POOJA MYSORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W GALLERIA DR
HENDERSON NV
89011-4800
US

IV. Provider business mailing address

4471 DEAN MARTIN DR UNIT 3909
LAS VEGAS NV
89103-4116
US

V. Phone/Fax

Practice location:
  • Phone: 702-963-7000
  • Fax:
Mailing address:
  • Phone: 631-833-8616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number100905
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number27240
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number100905
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: