Provider Demographics
NPI:1508852013
Name:WALL, DANIEL J (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2121 E COAST HWY
Mailing Address - Street 2:STE 250
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1932
Mailing Address - Country:US
Mailing Address - Phone:925-952-9003
Mailing Address - Fax:925-952-4323
Practice Address - Street 1:2121 E COAST HWY
Practice Address - Street 2:STE 250
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1932
Practice Address - Country:US
Practice Address - Phone:949-721-6000
Practice Address - Fax:949-721-6006
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA74764207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH39325Medicare UPIN
CA00A747640Medicare ID - Type Unspecified