Provider Demographics
NPI:1396049011
Name:CLARK, RYAN STEWART (DO)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:STEWART
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 FAIRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-8130
Mailing Address - Country:US
Mailing Address - Phone:937-980-7400
Mailing Address - Fax:937-980-7441
Practice Address - Street 1:1380 E STROOP RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4926
Practice Address - Country:US
Practice Address - Phone:937-293-3486
Practice Address - Fax:937-293-3605
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010728207R00000X, 207RC0000X
OH58.003689390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0100097Medicaid
OHH189631Medicare PIN
OH0100097Medicaid