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 1:190 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:
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:132 5TH AVE W STE 1AND2
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1825
Practice Address - Country:US
Practice Address - Phone:208-814-9800
Practice Address - Fax:208-933-9648
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13372207Q00000X, 208600000X
390200000X
CO6254111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1851556229Medicaid