1154481539 NPI number — SHOBA MENON MD

Table of content: SHOBA MENON MD (NPI 1154481539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154481539 NPI number — SHOBA MENON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENON
Provider First Name:
SHOBA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MULLOTH
Provider Other First Name:
SHOBA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154481539
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1866 WADING RIVER MANOR RD
Provider Second Line Business Mailing Address:
PO BOX 625
Provider Business Mailing Address City Name:
WADING RIVER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11792-2137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-929-8787
Provider Business Mailing Address Fax Number:
631-929-0350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1866 WADING RIVER MANOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADING RIVER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11792-2137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-929-8787
Provider Business Practice Location Address Fax Number:
631-929-0350
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2308051 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5536793 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9398762 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2504648 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: EP2144629 . This is a "VYTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: MS0805 . This is a "ATLANTIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 230805 . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: HB2144626 . This is a "VYTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: RH2144630 . This is a "VYTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 364487963 . This is a "MAGNACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 364487963 . This is a "DEVON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 136728 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 364487963 . This is a "EMP GOVT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5607709 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 364487963 . This is a "IGA" identifier . This identifiers is of the category "OTHER".
  • Identifier: NY230805 . This is a "1199" identifier . This identifiers is of the category "OTHER".




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