Provider Demographics
NPI:1710144993
Name:PENUKONDA, ISMAIL S (MD)
Entity Type:Individual
Prefix:DR
First Name:ISMAIL
Middle Name:S
Last Name:PENUKONDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 BRIGHTON CV
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-1101
Mailing Address - Country:US
Mailing Address - Phone:737-786-5700
Mailing Address - Fax:817-818-1805
Practice Address - Street 1:3213 BRIGHTON CV
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-1101
Practice Address - Country:US
Practice Address - Phone:737-786-5700
Practice Address - Fax:817-818-1805
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA06298Medicaid