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General NPI Number Information
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NPI Number | 1558354407
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Entity Type | Individual
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Provider Name | DANIEL EVAN VIDERS MD
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Gender | Male
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Dates
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Enumeration Date | 08/25/2005
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 207 SOUTHBRIDGE ST
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City | AUBURN
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State | MA
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Zip | 01501-2548
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Country | US
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Telephone | 508-832-7118
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Fax | 508-832-4758
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Provider Business Mailing Address
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Address Line | 207 SOUTHBRIDGE ST
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City | AUBURN
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State | MA
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Zip | 01501-2548
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Country | US
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Telephone | 508-832-7118
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Fax | 508-832-7166
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 042219
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 11477
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License Number State | RI
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 75666
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License Number State | MA
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