Provider Demographics
NPI:1679065411
Name:VANDENBERG, CLAY (OTA)
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 S CLYDE MORRIS BLVD APT 1008
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-9035
Mailing Address - Country:US
Mailing Address - Phone:973-800-4220
Mailing Address - Fax:
Practice Address - Street 1:1 ORTHOPAEDIC PL
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4202
Practice Address - Country:US
Practice Address - Phone:904-825-0540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1770020919207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty