Provider Demographics
NPI:1851556229
Name:BRUNSON, CLARENCE JARON (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:JARON
Last Name:BRUNSON
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 1:701 LEWISTON ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-9750
Mailing Address - Country:US
Mailing Address - Phone:208-962-3251
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-9750
Practice Address - Country:US
Practice Address - Phone:208-962-3251
Practice Address - Fax:208-962-2313
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6254111N00000X
IDM-13372208600000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No111N00000XChiropractic ProvidersChiropractor
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1851556229Medicaid