Provider Demographics
NPI:1962881128
Name:MATHIS-UWANOGHO, MYRA L (MD)
Entity type:Individual
Prefix:DR
First Name:MYRA
Middle Name:L
Last Name:MATHIS-UWANOGHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:L
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:300 CRITTENDEN BLVD BOX PSYCH
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-8375
Mailing Address - Fax:
Practice Address - Street 1:300 CRITTENDEN BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-3108
Practice Address - Country:US
Practice Address - Phone:585-275-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3048852084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000315Medicaid
CT008088729Medicaid
CT008056168Medicaid
CT004082286Medicaid