Provider Demographics
NPI:1205831906
Name:SUGAR, JEROME O (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:O
Last Name:SUGAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEROME
Other - Middle Name:
Other - Last Name:SUGAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:132 DEER HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2171
Mailing Address - Country:US
Mailing Address - Phone:203-233-3378
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:STE 531
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-419-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020592207Y00000X
FLME 126969207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB38157Medicare UPIN
CT040000146Medicare ID - Type Unspecified
CT1205921Medicaid