Basic Information
| Provider Information | |||||||||
| NPI: | 1679065411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDENBERG | ||||||||
| FirstName: | CLAY | ||||||||
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| Credential: | OTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1756 S CLYDE MORRIS BLVD APT 1008 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321199035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738004220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 ORTHOPAEDIC PL | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048250540 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2018 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 1770020919 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.