Provider Demographics
NPI:1528054095
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 1:4435 BROCKTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4004
Mailing Address - Country:US
Mailing Address - Phone:951-683-6830
Mailing Address - Fax:951-228-9458
Practice Address - Street 1:4435 BROCKTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4004
Practice Address - Country:US
Practice Address - Phone:951-683-6830
Practice Address - Fax:951-228-9458
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87744207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A877440Medicaid
CA00A877440Medicaid
CA00A877441Medicare ID - Type Unspecified