Provider Demographics
NPI:1790757490
Name:BLANK, BRUCE GARY (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GARY
Last Name:BLANK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 N 4TH ST
Mailing Address - Street 2:SUITE 27
Mailing Address - City:MARTINS FERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43935-1691
Mailing Address - Country:US
Mailing Address - Phone:740-633-4188
Mailing Address - Fax:740-633-4716
Practice Address - Street 1:92 N 4TH ST
Practice Address - Street 2:SUITE 27
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935-1691
Practice Address - Country:US
Practice Address - Phone:740-633-4188
Practice Address - Fax:740-633-4716
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002569213E00000X
WV00239213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6491296002OtherCIGNA
2102991OtherMAMSI
OH2569OtherHEALTH PLAN
480027937OtherRAILROAD MEDICARE
WV0099535000Medicaid
OH0747213Medicaid
OH000000141557OtherANTHEM BCBC
PA01548623Medicaid
4295099OtherAETNA
OH2569OtherHEALTH PLAN
WVBL0882671Medicare ID - Type Unspecified
OHBL0644229Medicare ID - Type Unspecified
OH0747213Medicaid