Provider Demographics
NPI:1770875114
Name:VANDERWALL, BRADEN (MD)
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:VANDERWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 RAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-5160
Mailing Address - Country:US
Mailing Address - Phone:941-552-7508
Mailing Address - Fax:941-552-7605
Practice Address - Street 1:5955 RAND BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-5160
Practice Address - Country:US
Practice Address - Phone:941-552-7508
Practice Address - Fax:941-552-7605
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121191207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013600900Medicaid
TN1525174Medicaid
VA1770875114Medicaid