Provider Demographics
NPI:1801540273
Name:TUGGLE, DEMETRIC ANTRON
Entity type:Individual
Prefix:
First Name:DEMETRIC
Middle Name:ANTRON
Last Name:TUGGLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 HEARTHSTONE PL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7286
Mailing Address - Country:US
Mailing Address - Phone:470-754-5144
Mailing Address - Fax:
Practice Address - Street 1:3480 HEARTHSTONE PL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7286
Practice Address - Country:US
Practice Address - Phone:470-754-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040114469172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver