Provider Demographics
NPI:1710080031
Name:REIDMAN, DANIEL ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ANTHONY
Last Name:REIDMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2624
Mailing Address - Country:US
Mailing Address - Phone:803-394-7916
Mailing Address - Fax:
Practice Address - Street 1:324 GANNETT DR STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3266
Practice Address - Country:US
Practice Address - Phone:803-803-7538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0583092085R0202X
WAOP000018892085R0202X
SC10112085R0202X
MEDO26672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC010115Medicaid
SC010115Medicaid