Basic Information
| Provider Information | |||||||||
| NPI: | 1679560395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SARGENT | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 BELFORT RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463013 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 RANDALLIA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603734433 | ||||||||
| FaxNumber: | 2607376704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301052791 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10785765 | 01 | CAQH PROVIDER ID | OTHER | 381303843 | 01 | TAX ID | OTHER | 4879960 | 05 | MI | MEDICAID |