Healthcare Provider Details

I. General information

NPI: 1396049011
Provider Name (Legal Business Name): RYAN STEWART CLARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 E STROOP RD
KETTERING OH
45429-4926
US

IV. Provider business mailing address

1103 FAIRINGTON DR
SIDNEY OH
45365-8130
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-3486
  • Fax: 937-293-3605
Mailing address:
  • Phone: 937-980-7400
  • Fax: 937-980-7441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number58.003689
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34010728
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34010728
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: