Provider Demographics
NPI:1386701357
Name:PENUGONDA, DWARAKI BAI (MD)
Entity type:Individual
Prefix:DR
First Name:DWARAKI
Middle Name:BAI
Last Name:PENUGONDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:166 HANOVER ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-3549
Mailing Address - Country:US
Mailing Address - Phone:570-823-8184
Mailing Address - Fax:570-823-6460
Practice Address - Street 1:166 HANOVER ST
Practice Address - Street 2:SUITE 307
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3549
Practice Address - Country:US
Practice Address - Phone:570-823-8184
Practice Address - Fax:570-823-6460
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD035084Y208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006538020001Medicaid
PA0006538020001Medicaid