Provider Demographics
NPI:1427045301
Name:MENON, MRIDULA (MD)
Entity Type:Individual
Prefix:DR
First Name:MRIDULA
Middle Name:
Last Name:MENON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:6 BLACKSTONE VALLEY PL
Practice Address - Street 2:SUITE 701
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1179
Practice Address - Country:US
Practice Address - Phone:401-333-3111
Practice Address - Fax:401-334-1217
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD11557207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2081156Medicaid
MAA37793Medicare ID - Type Unspecified
MA2081156Medicaid