Provider Demographics
NPI:1790850923
Name:BRUNTON, CLARKE A JR (DO)
Entity Type:Individual
Prefix:
First Name:CLARKE
Middle Name:A
Last Name:BRUNTON
Suffix:JR
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 1:1100 W. 21ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-2345
Mailing Address - Fax:575-769-9013
Practice Address - Street 1:1100 W. 21ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-2345
Practice Address - Fax:575-769-9013
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA1160012084P0800X
NMA-1160-012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry