Provider Demographics
NPI:1114583515
Name:CARUSO, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CARUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-1011
Mailing Address - Country:US
Mailing Address - Phone:614-824-8811
Mailing Address - Fax:740-919-0258
Practice Address - Street 1:19 BURREED CT
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:OH
Practice Address - Zip Code:43062-9638
Practice Address - Country:US
Practice Address - Phone:614-824-8811
Practice Address - Fax:740-919-0258
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor