Provider Demographics
NPI:1558312199
Name:BLEA, CLARENCE W (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:W
Last Name:BLEA
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:SUITE 150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-381-3008
Practice Address - Fax:208-381-4314
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6717207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine