Provider Demographics
NPI:1437171113
Name:VANDOREN, CLAY J (DO)
Entity Type:Individual
Prefix:MR
First Name:CLAY
Middle Name:J
Last Name:VANDOREN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 HOMER AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1206
Mailing Address - Country:US
Mailing Address - Phone:607-428-5074
Mailing Address - Fax:607-428-5077
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:607-428-5074
Practice Address - Fax:607-428-5077
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194911-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01821916Medicaid
NY01821916Medicaid
AA0067Medicare PIN