Provider Demographics
NPI:1174503528
Name:WALLER, DANIEL MARK (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 LAUREL ST
Mailing Address - Street 2:STE 3170
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314
Mailing Address - Country:US
Mailing Address - Phone:515-283-0463
Mailing Address - Fax:
Practice Address - Street 1:411 LAUREL ST
Practice Address - Street 2:STE 3170
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314
Practice Address - Country:US
Practice Address - Phone:515-283-0463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28024207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0073957Medicaid
IA0073957Medicaid
IA04059Medicare PIN