MEDICARE: SRI DIVYA MUPPALA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2007013992	MO
2	207R00000X	Internal Medicine Physician	44863	KY

General Provider Information

NPI Number	:	1457557290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SRI DIVYA MUPPALA M.D.

Provider Business Mailing Address
First Line	:	2300 CHAMBER CENTER DR
Second Line	:	SUITE 200
City	:	LAKESIDE PARK
State	:	KY
Zip	:	41017-1673
Country	:	US
Telephone Number	:	859-344-5555
Fax Number	:	859-344-5552

Provider Business Practice Location Address
First Line	:	2091 N BEND RD
Second Line	:	HEBRON
City	:	HEBRON
State	:	KY
Zip	:	41048-9691
Country	:	US
Telephone Number	:	859-586-2200
Fax Number	:	859-586-4222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	09/13/2013

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Directions to “ SRI DIVYA MUPPALA M.D.” Practice Location

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