Provider Demographics
NPI:1588620611
Name:MENON, PRAMOD VIJAYAGOPAL (MD)
Entity Type:Individual
Prefix:MR
First Name:PRAMOD
Middle Name:VIJAYAGOPAL
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 LINDBERG DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-8064
Mailing Address - Country:US
Mailing Address - Phone:985-273-5027
Mailing Address - Fax:
Practice Address - Street 1:39 STARBRUSH CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7304
Practice Address - Country:US
Practice Address - Phone:985-871-4155
Practice Address - Fax:985-871-4483
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14635R207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1055841Medicaid
LAP00363789OtherRAILROAD MEDICARE
LA4F772Medicare PIN
LAI05354Medicare UPIN