Healthcare Provider Details

I. General information

NPI: 1811220957
Provider Name (Legal Business Name): SASI KIRAN PENUKONDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 ELIZABETH AVE
SHREVEPORT LA
71104-2123
US

IV. Provider business mailing address

2032 ELIZABETH AVE
SHREVEPORT LA
71104-2123
US

V. Phone/Fax

Practice location:
  • Phone: 318-698-0035
  • Fax: 318-698-0078
Mailing address:
  • Phone: 318-698-0035
  • Fax: 318-698-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number261269
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number325077
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: