Provider Demographics
NPI:1265751879
Name:ARUN K. PENUKONDA, M.D., F.R.C.S., P.A..
Entity type:Organization
Organization Name:ARUN K. PENUKONDA, M.D., F.R.C.S., P.A..
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARUN
Authorized Official - Middle Name:K
Authorized Official - Last Name:PENUKONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-574-4110
Mailing Address - Street 1:323 DEL PRADO BLVD. S.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990
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:239-574-5897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00623662086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDR169AMedicare PIN