Provider Demographics
NPI:1982658514
Name:NUGENT, SUSAN DENISE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DENISE
Last Name:NUGENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:DENISE
Other - Last Name:NUGENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:521 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2224
Mailing Address - Country:US
Mailing Address - Phone:949-933-7501
Mailing Address - Fax:
Practice Address - Street 1:3024 BREAKERS DR
Practice Address - Street 2:APT A
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-3254
Practice Address - Country:US
Practice Address - Phone:949-933-7501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7045237700000X
CAC43237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C432370Medicaid
CAC43237OtherSTATE LICENSE
CAZZZ26826ZMedicare ID - Type Unspecified
CA00C432370Medicaid