Provider Demographics
NPI:1346445624
Name:MENON, PREMA R (MD)
Entity Type:Individual
Prefix:
First Name:PREMA
Middle Name:R
Last Name:MENON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:89 BEAUMONT AVE
Mailing Address - Street 2:GIVEN D208D
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05405-1742
Mailing Address - Country:US
Mailing Address - Phone:802-656-3525
Mailing Address - Fax:802-656-3526
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:PULMONARY AND CRITICAL CARE DIVISION FAHC
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-3421
Practice Address - Country:US
Practice Address - Phone:802-847-1558
Practice Address - Fax:802-847-2444
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2015-01-05
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Provider Licenses
StateLicense IDTaxonomies
VT0420012263207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200872260AMedicaid
INOTH000Medicare UPIN
IN200872260AMedicaid