Provider Demographics
NPI:1053417113
Name:WALL, EVA (MD)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:
Other - Last Name:SLEPECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1415 PORTLAND AVE STE 245
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3022
Mailing Address - Country:US
Mailing Address - Phone:585-922-4518
Mailing Address - Fax:585-922-3950
Practice Address - Street 1:1415 PORTLAND AVE STE 245
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3022
Practice Address - Country:US
Practice Address - Phone:585-922-4518
Practice Address - Fax:585-922-3950
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221037208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G64188Medicare UPIN