Healthcare Provider Details

I. General information

NPI: 1811956311
Provider Name (Legal Business Name): SURESH K MENON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TAVERN RD SUITE 400
MARTINSBURG WV
25401-2845
US

IV. Provider business mailing address

148 LINDEN DR SUITE 101
WINCHESTER VA
22601-6909
US

V. Phone/Fax

Practice location:
  • Phone: 304-350-8733
  • Fax: 304-350-8655
Mailing address:
  • Phone: 540-504-0066
  • Fax: 540-678-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD55793
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD55793
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23521
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0055793
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number23521
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: