Ismail S Penukonda, MD
Individual provider Active NPI Family Medicine Physician · Grapevine, TX
NPI 1710144993 · NPPES record last updated Mar 29, 2024
Key facts
- NPI
- 1710144993
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- MD.204783 (LA)
- Practice address
- 3213 Brighton CV
Grapevine, TX 76051-1101 - Phone
- (737) 786-5700
- Fax
- (817) 818-1805
- NPI assigned
- May 16, 2008
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in LA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20130731000737 | LA | Order and Referring Only - Family Practice |
5395986400 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD.204783 | LA | MD | Family Medicine Physician |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | MD.204783 | LA | Yes |
Addresses
Primary practice location
3213 Brighton CV
Grapevine, TX 76051-1101
Mailing address
3213 Brighton CV
Grapevine, TX 76051-1101
Phone (737) 786-5700
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 06298 | Medicaid | LA |
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All providers in Grapevine, TX · Family Medicine Physician in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 29, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.