Basic Information
| Provider Information | |||||||||
| NPI: | 1053318089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYSORE | ||||||||
| FirstName: | VEENA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5100 AUTH WAY | ||||||||
| Address2: | KAISER PERMANENTE MARLOW HEIGHTS MEDICAL CENTER | ||||||||
| City: | SUITLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207464207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017025000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 12/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD038413 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D63315 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101246622 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036103171 | 05 | IL | MEDICAID |