Provider Demographics
NPI:1003861923
Name:CLANCY, TAMARA R (MD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:R
Last Name:CLANCY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:DENISE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3635 S CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-2300
Mailing Address - Country:US
Mailing Address - Phone:386-788-4263
Mailing Address - Fax:386-788-0679
Practice Address - Street 1:3635 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 900
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2300
Practice Address - Country:US
Practice Address - Phone:386-788-4263
Practice Address - Fax:386-788-0679
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065937207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E45732Medicare UPIN
FL27551Medicare ID - Type Unspecified