Healthcare Provider Details

I. General information

NPI: 1265751879
Provider Name (Legal Business Name): ARUN K. PENUKONDA, M.D., F.R.C.S., P.A..
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 DEL PRADO BLVD. S. SUITE 100
CAPE CORAL FL
33990
US

IV. Provider business mailing address

323 DEL PRADO BLVD. S. SUITE 100
CAPE CORAL FL
33990
US

V. Phone/Fax

Practice location:
  • Phone: 239-574-4110
  • Fax: 239-574-5897
Mailing address:
  • Phone: 239-574-4110
  • Fax: 239-574-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0062366
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME0062366
License Number StateFL

VIII. Authorized Official

Name: ARUN K PENUKONDA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 239-574-4110