Provider Demographics
NPI:1407210982
Name:MENON, ROHAN VENUGOPAL
Entity Type:Individual
Prefix:
First Name:ROHAN
Middle Name:VENUGOPAL
Last Name:MENON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8450
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LANE, BLDG B 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-284-7770
Practice Address - Fax:972-284-7780
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0337208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics