Provider Demographics
NPI:1639288822
Name:STEPHEN L DYGERT, MD
Entity Type:Organization
Organization Name:STEPHEN L DYGERT, MD
Other - Org Name:AFTON FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DYGERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-639-2701
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 AVENUE
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53235AMedicare ID - Type Unspecified