Healthcare Provider Details

I. General information

NPI: 1205831906
Provider Name (Legal Business Name): JEROME O SUGAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEROME SUGAR MD

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE STE 531
JACKSONVILLE FL
32256-9680
US

IV. Provider business mailing address

132 DEER HAVEN DR
PONTE VEDRA BEACH FL
32082-2171
US

V. Phone/Fax

Practice location:
  • Phone: 904-419-2054
  • Fax:
Mailing address:
  • Phone: 203-233-3378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number020592
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME 126969
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: