Provider Demographics
NPI:1184694895
Name:AMAYUN, CLARENCE BONOAN (MD)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:BONOAN
Last Name:AMAYUN
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 1:4070 E 100 N
Mailing Address - Street 2:SUITE106
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-8319
Mailing Address - Country:US
Mailing Address - Phone:765-453-8585
Mailing Address - Fax:765-453-8002
Practice Address - Street 1:3611 S REED RD
Practice Address - Street 2:SUITE 106
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3828
Practice Address - Country:US
Practice Address - Phone:765-453-8001
Practice Address - Fax:765-453-8002
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041643A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN142000Medicare PIN