Provider Demographics
NPI:1679882005
Name:MYSORE VENKATESH, BHAGYA (MD)
Entity type:Individual
Prefix:DR
First Name:BHAGYA
Middle Name:
Last Name:MYSORE VENKATESH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 EAST MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910
Mailing Address - Country:US
Mailing Address - Phone:517-485-1153
Mailing Address - Fax:
Practice Address - Street 1:901 EAST MICHIGAN AVENUE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910
Practice Address - Country:US
Practice Address - Phone:517-485-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097216208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics