MEDICARE: DR. NARAYANA G MEMULA 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	2085R0001X	Radiation Oncology Physician	C52162	CA
2	2085R0203X	Therapeutic Radiology Physician	R8431	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R8431	OTHER	MO	MEDICALLICENSE
2	R8431	OTHER	MO	MEDICAL LICENSE

General Provider Information

NPI Number	:	1568478238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NARAYANA G MEMULA M.D.

Provider Business Mailing Address
First Line	:	6770 BROWN LN
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-8652
Country	:	US
Telephone Number	:	573-560-1008
Fax Number	:	573-560-1008

Provider Business Practice Location Address
First Line	:	1800 MEDICAL CENTER DR
Second Line	:	SUITE 100
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1218
Country	:	US
Telephone Number	:	909-887-8800
Fax Number	:	909-887-5678

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	12/21/2021

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