Healthcare Provider Details

I. General information

NPI: 1851491377
Provider Name (Legal Business Name): MOHAN M MENON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 LAKE AVE SUITE 27
FORT WAYNE IN
46805-5428
US

IV. Provider business mailing address

1234 E. DUPONT RD. SUITE 1
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-5569
  • Fax: 260-422-6086
Mailing address:
  • Phone: 260-373-9728
  • Fax: 260-458-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number01028503A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: