Provider Demographics
NPI:1508838566
Name:VANLANDINGHAM, CLINT L (DPM)
Entity Type:Individual
Prefix:MR
First Name:CLINT
Middle Name:L
Last Name:VANLANDINGHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2600 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3001
Mailing Address - Country:US
Mailing Address - Phone:573-785-4546
Mailing Address - Fax:573-785-6959
Practice Address - Street 1:2600 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3001
Practice Address - Country:US
Practice Address - Phone:573-785-4546
Practice Address - Fax:573-785-6959
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014037662363LF0000X
MO2004001321213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO309166510Medicaid
MO309166510Medicaid
MO00014615Medicare PIN