Provider Demographics
NPI:1790954931
Name:NGUYEN, DEREK (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:NGUYEN
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 1:631 S QUAKER LN
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1043
Mailing Address - Country:US
Mailing Address - Phone:860-233-5133
Mailing Address - Fax:860-233-5212
Practice Address - Street 1:631 S QUAKER LN
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1043
Practice Address - Country:US
Practice Address - Phone:860-233-5133
Practice Address - Fax:860-233-5211
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT049412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid