Provider Demographics
NPI:1376120691
Name:CLARK, RYAN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 BARNHILL DR # MS 116
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5126
Mailing Address - Country:US
Mailing Address - Phone:937-508-9400
Mailing Address - Fax:
Practice Address - Street 1:635 BARNHILL DR # MS 116
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5126
Practice Address - Country:US
Practice Address - Phone:937-508-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11022512A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program