Provider Demographics
NPI:1114153236
Name:NUGENT, DYLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:
Last Name:NUGENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6308
Mailing Address - Fax:
Practice Address - Street 1:105 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5608
Practice Address - Country:US
Practice Address - Phone:864-797-7060
Practice Address - Fax:864-797-7065
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC81873207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200081102Medicaid