Healthcare Provider Details

I. General information

NPI: 1790850923
Provider Name (Legal Business Name): CLARKE A. BRUNTON JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W. 21ST
CLOVIS NM
88101
US

IV. Provider business mailing address

1100 W. 21ST
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax: 575-769-9013
Mailing address:
  • Phone: 575-769-2345
  • Fax: 575-769-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA116001
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA-1160-01
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: