Provider Demographics
NPI:1215018627
Name:PENUKONDA, ARUN K (MD, FRCS, PA)
Entity Type:Individual
Prefix:
First Name:ARUN
Middle Name:K
Last Name:PENUKONDA
Suffix:
Gender:M
Credentials:MD, FRCS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:239-574-4110
Mailing Address - Fax:239-574-5897
Practice Address - Street 1:323 DEL PRADO BLVD. S.
Practice Address - Street 2:SUITE 100
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990
Practice Address - Country:US
Practice Address - Phone:239-574-4110
Practice Address - Fax:239-673-6053
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00623662086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370617600Medicaid
FL15298Medicare ID - Type Unspecified
FL370617600Medicaid