Healthcare Provider Details

I. General information

NPI: 1497125926
Provider Name (Legal Business Name): NAVYA MOHAN MYSORE M.D.C.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2015
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 UNION ST
BROOKLYN NY
11215-7583
US

IV. Provider business mailing address

129 W 29TH ST FL 10
NEW YORK NY
10001-5105
US

V. Phone/Fax

Practice location:
  • Phone: 212-441-4400
  • Fax: 212-867-4353
Mailing address:
  • Phone: 415-658-6791
  • Fax: 212-867-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number280053
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: