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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 BLACKHAWK RD STE 140
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4832
Mailing Address - Country:US
Mailing Address - Phone:925-837-6000
Mailing Address - Fax:925-837-6011
Practice Address - Street 1:3860 BLACKHAWK RD STE 140
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4832
Practice Address - Country:US
Practice Address - Phone:925-837-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74764207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH39325Medicare UPIN
CA00A747640Medicare ID - Type Unspecified