Provider Demographics
NPI:1649622051
Name:DERVIEUX, THIERRY (PHD DABCC)
Entity type:Individual
Prefix:DR
First Name:THIERRY
Middle Name:
Last Name:DERVIEUX
Suffix:
Gender:M
Credentials:PHD DABCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 LIBERTY WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8356
Mailing Address - Country:US
Mailing Address - Phone:858-784-1673
Mailing Address - Fax:
Practice Address - Street 1:1261 LIBERTY WAY
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8356
Practice Address - Country:US
Practice Address - Phone:858-784-1673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYDERVT1246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory