Provider Demographics
NPI:1417061573
Name:MENON, PRASANNA I (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANNA
Middle Name:
Last Name:MENON
Suffix:I
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 GRANT RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-3855
Mailing Address - Country:US
Mailing Address - Phone:650-965-9155
Mailing Address - Fax:650-965-4105
Practice Address - Street 1:2204 GRANT RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3855
Practice Address - Country:US
Practice Address - Phone:650-965-9155
Practice Address - Fax:650-965-4105
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A460190Medicare ID - Type Unspecified