Provider Demographics
NPI:1336134014
Name:MENON, MOOTHEDATH (MD)
Entity Type:Individual
Prefix:
First Name:MOOTHEDATH
Middle Name:
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 1:661 W 1ST ST STE G
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2939
Mailing Address - Country:US
Mailing Address - Phone:714-665-9890
Mailing Address - Fax:714-665-9891
Practice Address - Street 1:661 W 1ST ST STE G
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2939
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:714-665-9891
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41105207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A411050Medicaid
CA00A411050Medicaid
CA00A411050Medicare ID - Type Unspecified