Provider Demographics
NPI:1114978574
Name:RUSKUSKY, JOHN L (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:RUSKUSKY
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 1:3305 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6237
Mailing Address - Country:US
Mailing Address - Phone:309-347-3886
Mailing Address - Fax:309-347-4002
Practice Address - Street 1:3305 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6237
Practice Address - Country:US
Practice Address - Phone:309-347-3886
Practice Address - Fax:309-347-4002
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002661213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT35879Medicare UPIN
ILK04574Medicare PIN