Provider Demographics
NPI:1003536798
Name:DERICK E. VERGNE, MD PLLC
Entity Type:Organization
Organization Name:DERICK E. VERGNE, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:857-239-1911
Mailing Address - Street 1:179 GREAT RD
Mailing Address - Street 2:STE 201
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720
Mailing Address - Country:US
Mailing Address - Phone:857-239-1911
Mailing Address - Fax:
Practice Address - Street 1:179 GREAT RD STE 201
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-5774
Practice Address - Country:US
Practice Address - Phone:857-239-1911
Practice Address - Fax:617-544-0937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty