1790962082 NPI number — DR. DEREK THOMAS SUENO-NOEL M.D.

Table of content: DR. DEREK THOMAS SUENO-NOEL M.D. (NPI 1790962082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790962082 NPI number — DR. DEREK THOMAS SUENO-NOEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUENO-NOEL
Provider First Name:
DEREK
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790962082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WAHOO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06349-2324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-694-4725
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6455 MACHINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-278-5475
Provider Business Practice Location Address Fax Number:
877-811-2184
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  051573 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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