Provider Demographics
NPI:1760451298
Name:NAGARAJA, MYSORE R (MD)
Entity type:Individual
Prefix:DR
First Name:MYSORE
Middle Name:R
Last Name:NAGARAJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17075 DEVONSHIRE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5407
Mailing Address - Country:US
Mailing Address - Phone:818-363-3105
Mailing Address - Fax:818-363-6178
Practice Address - Street 1:811 E 11TH ST STE 208
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4872
Practice Address - Country:US
Practice Address - Phone:909-982-2279
Practice Address - Fax:909-946-3070
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25685207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A256850Medicaid
CAW5281OtherMEDICARE ID
CAA24538Medicare UPIN