Basic Information
| Provider Information | |||||||||
| NPI: | 1811220957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENUKONDA | ||||||||
| FirstName: | SASI | ||||||||
| MiddleName: | KIRAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 BICENTENNIAL HWY | ||||||||
| Address2: | CONNECTICUT CHILDRENS MEDICAL CENTER | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011181962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137334101 | ||||||||
| FaxNumber: | 4137966821 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 BICENTENNIAL HWY | ||||||||
| Address2: | CONNECTICUT CHILDRENS MEDICAL CENTER | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011181962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137334101 | ||||||||
| FaxNumber: | 4137966821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 06/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 261269 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110103822A | 05 | MA | MEDICAID |