Healthcare Provider Details

I. General information

NPI: 1215018627
Provider Name (Legal Business Name): ARUN K PENUKONDA MD, FRCS, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
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

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 239-574-4110
  • Fax: 239-673-6053
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:
Title or Position:
Credential:
Phone: