1982658514 NPI number — SUSAN DENISE NUGENT M.D.

Table of content: SUSAN DENISE NUGENT M.D. (NPI 1982658514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982658514 NPI number — SUSAN DENISE NUGENT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUGENT
Provider First Name:
SUSAN
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NUGENT
Provider Other First Name:
SUSAN
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1982658514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
521 IRIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA DEL MAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92625-2224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-933-7501
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3024 BREAKERS DR
Provider Second Line Business Practice Location Address:
APT A
Provider Business Practice Location Address City Name:
CORONA DEL MAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92625-3254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-933-7501
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  HA7045 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: C43237 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00C432370 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C43237 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".