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Individual
DANIEL CHARLES WALLACE
Active
Individual
DANIEL CHARLES WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
53228
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01-42353
MEDICA
—
01
—
1083848063
BCBS
MN
05
—
1083848063
—
MN
01
—
P00860753
RAILROAD MEDICARE
—
Enumeration date
05/06/2009
Last updated
03/11/2021
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