Provider Demographics
NPI:1992826358
Name:WALLACE, DANYALE A (MD)
Entity Type:Individual
Prefix:DR
First Name:DANYALE
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W NORTH AVE
Mailing Address - Street 2:APT. 302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1248
Mailing Address - Country:US
Mailing Address - Phone:312-274-9694
Mailing Address - Fax:
Practice Address - Street 1:1901 W POLK STREET
Practice Address - Street 2:FLOOR 10
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-964-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336076552207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
217008OtherMEDICARE GROUP #
217008OtherMEDICARE GROUP #