Provider Demographics
NPI:1053600064
Name:MENON, POOJA SHAH (MD)
Entity type:Individual
Prefix:
First Name:POOJA
Middle Name:SHAH
Last Name:MENON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:POOJA
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1601 PRECISION PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1345
Mailing Address - Country:US
Mailing Address - Phone:619-205-6349
Mailing Address - Fax:
Practice Address - Street 1:678 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5736
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139740207Q00000X
CAA123263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine