Provider Demographics
NPI:1609140904
Name:RUSILKO, MATTHEW IVAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:IVAN
Last Name:RUSILKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:IVAN
Other - Middle Name:
Other - Last Name:RUSILKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1441 BRICKELL AVE
Mailing Address - Street 2:MIAMI INSTITUTE FOUR SEASONS SKY LOBBY
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33131
Mailing Address - Country:US
Mailing Address - Phone:305-624-0009
Mailing Address - Fax:
Practice Address - Street 1:1441 BRICKELL AVE
Practice Address - Street 2:MIAMI INSTITUTE FOUR SEASONS SKY LOBBY
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131
Practice Address - Country:US
Practice Address - Phone:305-624-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11598208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice