Basic Information
| Provider Information | |||||||||
| NPI: | 1396049011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | STEWART | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1103 FAIRINGTON DR | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453658130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379807400 | ||||||||
| FaxNumber: | 9379807441 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 E STROOP RD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454294926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372933486 | ||||||||
| FaxNumber: | 9372933605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34010728 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | 58.003689 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 34010728 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0100097 | 05 | OH | MEDICAID |