Healthcare Provider Details

I. General information

NPI: 1477572675
Provider Name (Legal Business Name): MOOTHEDATH A MENON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18056 WIKA RD SUITE A
APPLE VALLEY CA
92307-2125
US

IV. Provider business mailing address

18056 WIKA RD SUITE A
APPLE VALLEY CA
92307-2125
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-1090
  • Fax: 760-247-1415
Mailing address:
  • Phone: 760-242-1090
  • Fax: 760-247-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA41105
License Number StateCA

VIII. Authorized Official

Name: MOOTHEDATH A MENON
Title or Position: PHYSICIAN
Credential: MD
Phone: 760-242-1090