MEDICARE: EVA WALL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	221037	NY

General Provider Information

NPI Number	:	1053417113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVA WALL MD

Provider Business Mailing Address
First Line	:	1415 PORTLAND AVE STE 245
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-3022
Country	:	US
Telephone Number	:	585-922-4518
Fax Number	:	585-922-3950

Provider Business Practice Location Address
First Line	:	1415 PORTLAND AVE STE 245
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-3022
Country	:	US
Telephone Number	:	585-922-4518
Fax Number	:	585-922-3950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	02/08/2023

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