Healthcare Provider Details

I. General information

NPI: 1609454040
Provider Name (Legal Business Name): CLAY CORNELISON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE
POCATELLO ID
83201-4835
US

IV. Provider business mailing address

500 S 11TH AVE
POCATELLO ID
83201-4835
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-6214
  • Fax:
Mailing address:
  • Phone: 208-232-6214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number222123
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: