Provider Demographics
NPI:1720424476
Name:MANCHEZHATHU RAJAGOPALAMENON, REJEESH MENON (MD)
Entity type:Individual
Prefix:DR
First Name:REJEESH MENON
Middle Name:
Last Name:MANCHEZHATHU RAJAGOPALAMENON
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3043 NE 28TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-4518
Practice Address - Country:US
Practice Address - Phone:541-994-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60611570207R00000X, 208M00000X
ORMD214390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1720424476Medicaid
WAP01713934OtherRR PTAN WVH
WAG8957160, G8957161Medicare PIN