Healthcare Provider Details

I. General information

NPI: 1558354407
Provider Name (Legal Business Name): DANIEL EVAN VIDERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 SOUTHBRIDGE ST
AUBURN MA
01501-2548
US

IV. Provider business mailing address

207 SOUTHBRIDGE ST
AUBURN MA
01501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 508-832-7118
  • Fax: 508-832-4758
Mailing address:
  • Phone: 508-832-7118
  • Fax: 508-832-7166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number042219
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11477
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number75666
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: