Provider Demographics
NPI:1790303493
Name:NUGENT, CAROLINE GRACE (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLINE
Middle Name:GRACE
Last Name:NUGENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:636-458-5858
Mailing Address - Fax:636-458-6510
Practice Address - Street 1:16555 MANCHESTER RD STE 201
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1220
Practice Address - Country:US
Practice Address - Phone:636-458-5858
Practice Address - Fax:636-458-6510
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021042916208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200083457Medicaid