Healthcare Provider Details

I. General information

NPI: 1790757490
Provider Name (Legal Business Name): BRUCE GARY BLANK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 N 4TH ST SUITE 27
MARTINS FERRY OH
43935-1691
US

IV. Provider business mailing address

92 N 4TH ST SUITE 27
MARTINS FERRY OH
43935-1691
US

V. Phone/Fax

Practice location:
  • Phone: 740-633-4188
  • Fax: 740-633-4716
Mailing address:
  • Phone: 740-633-4188
  • Fax: 740-633-4716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36002569
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00239
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: