Provider Demographics
NPI:1689931867
Name:M.M.DEREN,MD,PC
Entity Type:Organization
Organization Name:M.M.DEREN,MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-443-5469
Mailing Address - Street 1:125 SHAW ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4900
Mailing Address - Country:US
Mailing Address - Phone:860-443-5469
Mailing Address - Fax:
Practice Address - Street 1:125 SHAW ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4900
Practice Address - Country:US
Practice Address - Phone:860-443-5469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15198208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
060000059Medicare PIN