Healthcare Provider Details

I. General information

NPI: 1255644555
Provider Name (Legal Business Name): SUNIL PENESETTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 22ND AVE
MONROE WI
53566-1569
US

IV. Provider business mailing address

515 22ND AVE
MONROE WI
53566-1569
US

V. Phone/Fax

Practice location:
  • Phone: 608-324-2000
  • Fax:
Mailing address:
  • Phone: 608-324-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14938
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number270212
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number69193-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: