Provider Demographics
NPI:1124179494
Name:MICHAEL PETRUSKA OD PC
Entity Type:Organization
Organization Name:MICHAEL PETRUSKA OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:484-223-6930
Mailing Address - Street 1:4379 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-8937
Mailing Address - Country:US
Mailing Address - Phone:610-759-0806
Mailing Address - Fax:610-515-1679
Practice Address - Street 1:2501 SHEILA LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-2041
Practice Address - Country:US
Practice Address - Phone:804-320-9457
Practice Address - Fax:804-320-9458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU94335Medicare UPIN
VA00V183M94Medicare ID - Type Unspecified