Provider Demographics
NPI:1821406091
Name:MENON, SUDHA
Entity Type:Individual
Prefix:MS
First Name:SUDHA
Middle Name:
Last Name:MENON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 LOMAS BLVD NE
Mailing Address - Street 2:UNMH FIFTH FLOOR
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2719
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:UNMH FIFTH FLOOR
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-4661
Practice Address - Fax:505-272-4628
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMRS 2014-0769207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program