=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982608717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL J WALLACE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2005
-----------------------------------------------------
Last Update Date | 03/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8750 WILSHIRE BLVD STE 210
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90211-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-652-0920
-----------------------------------------------------
Fax | 310-652-2482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18736
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90209-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-652-0920
-----------------------------------------------------
Fax | 310-360-4812
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | G30533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------