Healthcare Provider Details

I. General information

NPI: 1972516672
Provider Name (Legal Business Name): NARAYANA G MEMULA,MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WESTWOOD BLVD CANCER CENTER
POPLAR BLUFF MO
63901-3396
US

IV. Provider business mailing address

6770 BROWN LANE
POPLAR BLUFF MO
63901-8652
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-7721
  • Fax:
Mailing address:
  • Phone: 573-778-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NARAYANA G MEMULA
Title or Position: PRESIDENT
Credential: MD
Phone: 573-778-1131