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General NPI Number Information
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NPI Number | 1851491377
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Entity Type | Individual
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Provider Name | MOHAN M MENON M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/24/2006
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Last Update Date | 08/13/2012
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Provider Practice Location Address
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Address Line | 3030 LAKE AVE SUITE 27
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City | FORT WAYNE
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State | IN
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Zip | 46805-5428
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Country | US
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Telephone | 260-422-5569
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Fax | 260-422-6086
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Provider Business Mailing Address
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Address Line | 1234 E. DUPONT RD. SUITE 1
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City | FORT WAYNE
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State | IN
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Zip | 46825-1545
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Country | US
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Telephone | 260-373-9728
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Fax | 260-458-5664
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 01028503A
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License Number State | IN
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