Provider Demographics
NPI:1598862666
Name:PENUGONDA, SHARADA D (DPM)
Entity Type:Individual
Prefix:
First Name:SHARADA
Middle Name:D
Last Name:PENUGONDA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5656 BEE CAVES RD
Mailing Address - Street 2:D204
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5280
Mailing Address - Country:US
Mailing Address - Phone:512-327-9251
Mailing Address - Fax:512-327-9742
Practice Address - Street 1:5656 BEE CAVES RD
Practice Address - Street 2:D204
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-5280
Practice Address - Country:US
Practice Address - Phone:512-327-9251
Practice Address - Fax:512-327-9742
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1626213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183566201Medicaid
TX00AP45OtherGROUP PTAN
TX00AP45OtherGROUP PTAN