Provider Demographics
NPI:1164533386
Name:MENON, PADMAN A (MD)
Entity Type:Individual
Prefix:
First Name:PADMAN
Middle Name:A
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1157 FIRST COLONIAL RD STE 300
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2432
Practice Address - Country:US
Practice Address - Phone:757-333-8001
Practice Address - Fax:757-333-8002
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301017207N00000X
VA0101022994207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC04588OtherMEDICARE GROUP NUMBER
NC89013XMMedicaid
NC89135YUMedicaid
NC135YUOtherINDIVIDUAL NC BCBS
NC013XMOtherNC GRP # BCBS
VA010109868Medicaid
NC2003292OtherNC MEDICARE GRP #
VA010109868Medicaid
NC013XMOtherNC GRP # BCBS
VA003465K88Medicare ID - Type Unspecified