Provider Demographics
NPI:1508970856
Name:PETRUSKA, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PETRUSKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 BELVIDERE RD
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-2004
Mailing Address - Country:US
Mailing Address - Phone:908-454-2300
Mailing Address - Fax:908-454-1661
Practice Address - Street 1:1326 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2004
Practice Address - Country:US
Practice Address - Phone:908-454-2300
Practice Address - Fax:908-454-1661
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00616700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0180025Medicaid
NJ132482ZARBMedicare PIN
NJ6188970001Medicare NSC