Provider Demographics
NPI:1013066083
Name:VERGNE, DERICK E (MD)
Entity Type:Individual
Prefix:DR
First Name:DERICK
Middle Name:E
Last Name:VERGNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
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:01720-5774
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
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2493762084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027417Medicaid