Healthcare Provider Details

I. General information

NPI: 1982608717
Provider Name (Legal Business Name): DANIEL J WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/22/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8750 WILSHIRE BLVD STE 210
BEVERLY HILLS CA
90211-2703
US

IV. Provider business mailing address

PO BOX 18736
BEVERLY HILLS CA
90209-4736
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-0920
  • Fax: 310-652-2482
Mailing address:
  • Phone: 310-652-0920
  • Fax: 310-360-4812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberG30533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: