Provider Demographics
NPI:1639129851
Name:RUSKUSKY, JEFFREY ROBERT (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
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 1:4716 W LYNNBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2729
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:309-347-3668
Practice Address - Fax:309-347-3890
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU98929Medicare UPIN
ILK04563Medicare PIN