Healthcare Provider Details

I. General information

NPI: 1326713793
Provider Name (Legal Business Name): DEREK VUONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ROUTE 9 STE 1308
QUEENSBURY NY
12804-1749
US

IV. Provider business mailing address

11103 ROCKAWAY ST
MALTA NY
12020-5226
US

V. Phone/Fax

Practice location:
  • Phone: 518-745-1200
  • Fax:
Mailing address:
  • Phone: 626-525-3016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number009434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: