Provider Demographics
NPI:1659816213
Name:SHOBA MENON MD, PC
Entity Type:Organization
Organization Name:SHOBA MENON MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHOBA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-929-8787
Mailing Address - Street 1:P.O. BOX 625
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2137
Mailing Address - Country:US
Mailing Address - Phone:631-929-8787
Mailing Address - Fax:631-929-0350
Practice Address - Street 1:1866 WADING RIVER MANOR RD
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2137
Practice Address - Country:US
Practice Address - Phone:631-929-8787
Practice Address - Fax:631-929-0350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty