Provider Demographics
NPI:1558354407
Name:VIDERS, DANIEL EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:EVAN
Last Name:VIDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:207 SOUTHBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2548
Mailing Address - Country:US
Mailing Address - Phone:508-832-7118
Mailing Address - Fax:508-832-7166
Practice Address - Street 1:207 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2548
Practice Address - Country:US
Practice Address - Phone:508-832-7118
Practice Address - Fax:508-832-4758
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2023-11-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT042219207N00000X
RI11477207N00000X
MA75666207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043158835OtherCOMMERCIAL
MAJ12248OtherBC BS OF MASS
CT001422196OtherTITLE 19 INS
MA997001OtherNETWORK HEALTH
CTP1705911OtherOXFORD HEALTH PLANS
CT00142219600OtherBLUE CARE FAMILY
MA010075666M02OtherANTHEM BC BS
MA000000028685OtherBMC HEALTH NET
MA0303009OtherUNITED HEALTH PLANS
MA075666OtherTUFTS MASS
CT010042219CT02OtherANTHEM BC BS
MA17462OtherHEALTH OF NEW ENGLAND
MA3092917Medicaid
CT2V2311OtherHEALTH NET
MA4294OtherHARVARD PILGRIM
MA620067OtherUS HEALTH CARE
CT758835OtherCONNECTICARE