Provider Demographics
NPI:1790962082
Name:SUENO-NOEL, DEREK THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:THOMAS
Last Name:SUENO-NOEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:860-694-4725
Mailing Address - Fax:
Practice Address - Street 1:6455 MACHINE DR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21005
Practice Address - Country:US
Practice Address - Phone:410-278-5475
Practice Address - Fax:877-811-2184
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051573207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine