Provider Demographics
NPI:1033114384
Name:MENON, PREM KUMAR (M D)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:KUMAR
Last Name:MENON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 FLANDERS DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9169
Mailing Address - Country:US
Mailing Address - Phone:225-766-6931
Mailing Address - Fax:225-766-9413
Practice Address - Street 1:5217 FLANDERS DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9169
Practice Address - Country:US
Practice Address - Phone:225-766-6931
Practice Address - Fax:225-766-9413
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07041R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1904953Medicaid
LAE46095Medicare UPIN
LA1904953Medicaid