Provider Demographics
NPI:1346745080
Name:REID, DANNY STEPHEN
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:STEPHEN
Last Name:REID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-6371
Mailing Address - Country:US
Mailing Address - Phone:540-992-3669
Mailing Address - Fax:540-344-5556
Practice Address - Street 1:557 RIDGE RD
Practice Address - Street 2:
Practice Address - City:TROUTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24175-6371
Practice Address - Country:US
Practice Address - Phone:540-992-3669
Practice Address - Fax:540-344-5556
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24701172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid