Provider Demographics
NPI:1891757555
Name:WALRATH, DANIEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:WALRATH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:240 MAPLE AVE
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8475
Mailing Address - Country:US
Mailing Address - Phone:262-929-1900
Mailing Address - Fax:262-363-1949
Practice Address - Street 1:240 MAPLE AVE
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8475
Practice Address - Country:US
Practice Address - Phone:262-929-1900
Practice Address - Fax:262-363-1949
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI22567207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30372200Medicaid
WI30372200Medicaid
WI000201674Medicare ID - Type Unspecified
683750655Medicare PIN