Healthcare Provider Details

I. General information

NPI: 1265672018
Provider Name (Legal Business Name): ANA MARIA VAN DER WALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 MANATEE AVE W
BRADENTON FL
34205-2557
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-1881
  • Fax: 941-795-3924
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME121065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: