Individual
DANIEL CHARLES WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
701 DELLWOOD ST S, CAMBRIDGE, MN 55008-1920
(763) 689-7700
Mailing address
2925 CHICAGO AVE, MINNEAPOLIS, MN 55407-1321
(612) 262-5000
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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