Healthcare Provider Details

I. General information

NPI: 1710965777
Provider Name (Legal Business Name): EVA PERDAHL-WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 06/11/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 2ND ST NE
WASHINGTON DC
20002-8100
US

IV. Provider business mailing address

700 2ND ST NE
WASHINGTON DC
20002-8100
US

V. Phone/Fax

Practice location:
  • Phone: 202-346-3690
  • Fax: 202-346-3689
Mailing address:
  • Phone: 202-346-3690
  • Fax: 202-346-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number0101048243
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberD0048014
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD037721
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: