Provider Demographics
NPI:1275525875
Name:WALLACE, DANIEL LELAND (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LELAND
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-267-0800
Mailing Address - Fax:616-267-0801
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 5100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-267-0800
Practice Address - Fax:616-267-0801
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM33350478Medicare PIN
MID16139020Medicare PIN
MIG18816Medicare UPIN