Provider Demographics
NPI:1154481539
Name:MENON, SHOBA (MD)
Entity Type:Individual
Prefix:
First Name:SHOBA
Middle Name:
Last Name:MENON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHOBA
Other - Middle Name:
Other - Last Name:MULLOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1866 WADING RIVER MANOR RD
Mailing Address - Street 2:PO BOX 625
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2137
Mailing Address - Country:US
Mailing Address - Phone:631-929-8787
Mailing Address - Fax:631-929-0350
Practice Address - Street 1:1866 WADING RIVER MANOR RD
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2137
Practice Address - Country:US
Practice Address - Phone:631-929-8787
Practice Address - Fax:631-929-0350
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2308051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5536793OtherCIGNA
9398762OtherPHCS
2504648OtherUHC
EP2144629OtherVYTRA
MS0805OtherATLANTIS
230805OtherHIP
HB2144626OtherVYTRA
RH2144630OtherVYTRA
364487963OtherMAGNACARE
364487963OtherDEVON
136728OtherANTHEM
364487963OtherEMP GOVT
5607709OtherFIRST HEALTH
364487963OtherIGA
NY230805Other1199