Provider Demographics
NPI:1982608717
Name:WALLACE, DANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 18736
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-4736
Mailing Address - Country:US
Mailing Address - Phone:310-652-0920
Mailing Address - Fax:310-360-4812
Practice Address - Street 1:8750 WILSHIRE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2703
Practice Address - Country:US
Practice Address - Phone:310-652-0920
Practice Address - Fax:310-652-2482
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG30533207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPG0080544002OtherBLUE SHIELD OF CA
CA953744782OtherBLUE CROSS
CA00G305330OtherBLUE SHIELD
CAA44455Medicare UPIN
CA953744782OtherBLUE CROSS