Provider Demographics
NPI:1831410240
Name:MENON, DEEPA VIJAYKUMAR
Entity type:Individual
Prefix:MRS
First Name:DEEPA
Middle Name:VIJAYKUMAR
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 1:3400 MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122
Mailing Address - Country:US
Mailing Address - Phone:410-360-1509
Mailing Address - Fax:410-360-4209
Practice Address - Street 1:3400 MOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122
Practice Address - Country:US
Practice Address - Phone:410-360-1509
Practice Address - Fax:410-360-4209
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD18277OtherLICENSE NUMBER