Provider Demographics
NPI:1760641476
Name:LYDDANE, CLAY EARL (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:CLAY
Middle Name:EARL
Last Name:LYDDANE
Suffix:
Gender:M
Credentials:MD PHD
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Mailing Address - Street 1:3311 E MURDOCK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3054
Mailing Address - Country:US
Mailing Address - Phone:316-689-9185
Mailing Address - Fax:316-689-9909
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-689-9185
Practice Address - Fax:316-689-9909
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-35145208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200740730AMedicaid
KS003719111Medicare Oscar/Certification