Provider Demographics
NPI:1770673568
Name:DUNN, CLARENCE (MD)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:DUNN
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 1:302 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5324
Mailing Address - Country:US
Mailing Address - Phone:318-322-2202
Mailing Address - Fax:318-322-9949
Practice Address - Street 1:302 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5324
Practice Address - Country:US
Practice Address - Phone:318-322-2202
Practice Address - Fax:318-322-9949
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021090174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721480315OtherFEDERAL TAX ID
LA100015461OtherRAILROAD MEDICARE #
LA1672513Medicaid
LA100015461OtherRAILROAD MEDICARE #
LAG03427Medicare UPIN