Provider Demographics
NPI:1326075094
Name:CLANCY, CORNELIUS J (MD)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:J
Last Name:CLANCY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CORNELIUS
Other - Middle Name:JOSEPH
Other - Last Name:CLANCY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-0606
Mailing Address - Fax:352-265-0678
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0606
Practice Address - Fax:352-265-0678
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87778207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
I00279Medicare UPIN
FLU1947ZMedicare PIN