Provider Demographics
NPI:1124123633
Name:MENON, VIJAY (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:MENON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 AINTREE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-4987
Mailing Address - Country:US
Mailing Address - Phone:317-379-6341
Mailing Address - Fax:
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:270-737-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY556132080N0001X
IN010568242080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200406490Medicaid
G21353Medicare UPIN