Healthcare Provider Details

I. General information

NPI: 1891080222
Provider Name (Legal Business Name): DANIELLE WALLACH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2356 MEADOWS BLVD
CASTLE ROCK CO
80109-8410
US

IV. Provider business mailing address

1900 LITTLE RAVEN ST APT #522
DENVER CO
80202-7163
US

V. Phone/Fax

Practice location:
  • Phone: 303-649-3380
  • Fax: 303-649-3381
Mailing address:
  • Phone: 954-579-1127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number55756
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: