Provider Demographics
NPI:1316014954
Name:MENON, RAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJ
Middle Name:
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 S BRISTOL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7300
Mailing Address - Country:US
Mailing Address - Phone:714-556-6666
Mailing Address - Fax:714-556-4548
Practice Address - Street 1:3620 S BRISTOL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7300
Practice Address - Country:US
Practice Address - Phone:714-556-6666
Practice Address - Fax:714-556-4548
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA38792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A387920Medicaid
A85176OtherUPIN
A85176OtherUPIN