Provider Demographics
NPI:1407381114
Name:WIDO, DANIEL MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MARK
Last Name:WIDO
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 1:8901 ROCKVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0001
Mailing Address - Country:US
Mailing Address - Phone:301-295-7850
Mailing Address - Fax:301-295-7850
Practice Address - Street 1:WALTER REED NMMC 8901 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5000
Practice Address - Country:US
Practice Address - Phone:301-295-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0101265238208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN