Provider Demographics
NPI:1508844929
Name:DYGERT, STEPHEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:DYGERT
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:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:NY
Mailing Address - Zip Code:13730-0025
Mailing Address - Country:US
Mailing Address - Phone:607-639-2701
Mailing Address - Fax:607-639-3333
Practice Address - Street 1:25 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:NY
Practice Address - Zip Code:13730-2129
Practice Address - Country:US
Practice Address - Phone:607-639-2701
Practice Address - Fax:607-639-3333
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1084291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00570503Medicaid
NYJ300039963Medicare PIN
B81209Medicare UPIN