Basic Information
| Provider Information | |||||||||
| NPI: | 1588620611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENON | ||||||||
| FirstName: | PRAMOD | ||||||||
| MiddleName: | VIJAYAGOPAL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1810 LINDBERG DR STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704588064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9852735027 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 39 STARBRUSH CIR | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704337304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858714155 | ||||||||
| FaxNumber: | 9858714483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 14635R | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 14635R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 1055841 | 05 | LA | MEDICAID | P00363789 | 01 | LA | RAILROAD MEDICARE | OTHER |