Provider Demographics
NPI:1114987641
Name:VANTERPOOL, CLYDE CALENSO (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:CALENSO
Last Name:VANTERPOOL
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:PO BOX 9034
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-0134
Mailing Address - Country:US
Mailing Address - Phone:863-835-2158
Mailing Address - Fax:
Practice Address - Street 1:6801 US HIGHWAY 27 N STE B1
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1000
Practice Address - Country:US
Practice Address - Phone:863-991-9060
Practice Address - Fax:863-991-9069
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377470800Medicaid
FL377470800Medicaid
F42068Medicare UPIN