Basic Information
| Provider Information | |||||||||
| NPI: | 1851491377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENON | ||||||||
| FirstName: | MOHAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739728 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 LAKE AVE | ||||||||
| Address2: | SUITE 27 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604225569 | ||||||||
| FaxNumber: | 2604226086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 01028503A | IN | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 100054450 | 05 | IN | MEDICAID |