Active NPI
Jack Surgenor
- Registered Dietitian
- Durham, CT
National Provider Identifier
1093677650
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- 3048
- Practice address
- 20 Laurel TRL
Durham, CT 06422-3400 - Phone
- (203) 464-9095
- NPI assigned
- Dec 2, 2025
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 3048 | CT | Primary |
Addresses
Primary practice location
20 Laurel TRL
Durham, CT 06422-3400
Mailing address
20 Laurel TRL
Durham, CT 06422-3400
Phone (203) 464-9095
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3048 | CT | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1764633600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1764633600000",
"number": "1093677650",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "20 LAUREL TRL",
"city": "DURHAM",
"state": "CT",
"postal_code": "064223400",
"telephone_number": "203-464-9095"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "20 LAUREL TRL",
"city": "DURHAM",
"state": "CT",
"postal_code": "064223400",
"telephone_number": "203-464-9095"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SURGENOR",
"first_name": "JACK",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2025-12-02",
"last_updated": "2025-12-02",
"certification_date": "2025-12-02",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "CT",
"license": "3048",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Durham, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.