Provider Demographics
NPI:1568877546
Name:BLECK, RYAN KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:KENNETH
Last Name:BLECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 W HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:419-633-4169
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11017965A207Q00000X
OH34.012817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine