Provider Demographics
NPI:1811232820
Name:FALL RIVER DERMATOLOGY PC
Entity type:Organization
Organization Name:FALL RIVER DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:VIDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-847-6616
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:508-917-8706
Practice Address - Street 1:191 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3050
Practice Address - Country:US
Practice Address - Phone:508-567-4550
Practice Address - Fax:508-917-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-02
Last Update Date:2012-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247239207N00000X
MA249077207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty