Healthcare Provider Details

I. General information

NPI: 1851556229
Provider Name (Legal Business Name): CLARENCE JARON BRUNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 5TH AVE W STE 1AND2
JEROME ID
83338-1825
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-9800
  • Fax: 208-933-9648
Mailing address:
  • Phone:
  • Fax: 208-962-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6254
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-13372
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-13372
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: