1568478238 NPI number — DR. NARAYANA G MEMULA M.D.

Table of content: DR. NARAYANA G MEMULA M.D. (NPI 1568478238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568478238 NPI number — DR. NARAYANA G MEMULA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEMULA
Provider First Name:
NARAYANA
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEMULA
Provider Other First Name:
NARAYANA
Provider Other Middle Name:
GOUD
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.B.B.S.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568478238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92411-1218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-887-8800
Provider Business Practice Location Address Fax Number:
909-887-5678
Provider Enumeration Date:
08/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  C52162 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X , with the licence number: R8431 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R8431 . This is a "MEDICALLICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: R8431 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".