Provider Demographics
NPI:1710965777
Name:PERDAHL-WALLACE, EVA (MD)
Entity Type:Individual
Prefix:DR
First Name:EVA
Middle Name:
Last Name:PERDAHL-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 1:700 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-8100
Mailing Address - Country:US
Mailing Address - Phone:202-346-3690
Mailing Address - Fax:202-346-3689
Practice Address - Street 1:700 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-8100
Practice Address - Country:US
Practice Address - Phone:202-346-3690
Practice Address - Fax:202-346-3689
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010482432080P0207X
MDD00480142080P0207X
DCMD0377212080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006712215Medicaid
VA006712215Medicaid
F79050Medicare UPIN