Basic Information
| Provider Information | |||||||||
| NPI: | 1265693543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAVINDRANATHA MENON | ||||||||
| FirstName: | PRAHARSHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RAVINDRANATHA MENON | ||||||||
| OtherFirstName: | PRAHARSHA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2084 HEADLAND DR | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL CENTER EASY POINT, LLC | ||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303442135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049655691 | ||||||||
| FaxNumber: | 4049655710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2084 HEADLAND DR | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL CENTER EAST POINT, LLC | ||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303442135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049655691 | ||||||||
| FaxNumber: | 4049655710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2008 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 066627 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.