Provider Demographics
NPI:1063606721
Name:MENON, NATHAN GOPI (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:GOPI
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-5611
Mailing Address - Country:US
Mailing Address - Phone:325-481-2099
Mailing Address - Fax:325-481-2001
Practice Address - Street 1:4450 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-5611
Practice Address - Country:US
Practice Address - Phone:325-481-2099
Practice Address - Fax:325-481-2001
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24233207XS0106X, 208200000X
NMRS2020-0443207XS0106X
TXT4980208200000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00967659Medicare PIN
ME4280472Medicare PIN