Provider Demographics
NPI:1134167950
Name:BLANK, HARLEY MYRON (MD)
Entity type:Individual
Prefix:DR
First Name:HARLEY
Middle Name:MYRON
Last Name:BLANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5969 E BROAD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1546
Mailing Address - Country:US
Mailing Address - Phone:614-864-0670
Mailing Address - Fax:614-864-5426
Practice Address - Street 1:1243 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:146-251-1800
Practice Address - Fax:614-251-1818
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35027415207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0167939Medicaid
OH0167939Medicaid
0367655Medicare PIN