Provider Demographics
NPI:1548416910
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:O D
Authorized Official - Phone:908-454-2300
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-17
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00616700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0180025Medicaid
NJ0180025Medicaid
NJ6188970001Medicare NSC