Healthcare Provider Details

I. General information

NPI: 1336134014
Provider Name (Legal Business Name): MOOTHEDATH A MENON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

IV. Provider business mailing address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-9890
  • Fax: 714-665-9891
Mailing address:
  • Phone: 714-665-9890
  • Fax: 714-665-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA41105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: