Provider Demographics
NPI:1801281928
Name:SARADA PENUKONDA MD
Entity type:Organization
Organization Name:SARADA PENUKONDA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARADA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENUKONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-574-3382
Mailing Address - Street 1:323 DEL PRADO BLVD S STE 100
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1747
Mailing Address - Country:US
Mailing Address - Phone:239-574-3382
Mailing Address - Fax:239-574-5897
Practice Address - Street 1:323 DEL PRADO BLVD S STE 100
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1747
Practice Address - Country:US
Practice Address - Phone:239-574-3382
Practice Address - Fax:239-574-5897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250647500Medicaid
27412OtherASK MEDICARE
FL250647500Medicaid