=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073074266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE MARIE ERDAHL DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2019
-----------------------------------------------------
Last Update Date | 11/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 WOODMAN DR STE 105
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45432-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-723-7772
-----------------------------------------------------
Fax | 937-226-9605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 WOODMAN DR STE 105
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45432-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-723-7772
-----------------------------------------------------
Fax | 937-226-9605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 34016439
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------