Provider Demographics
NPI:1679001101
Name:PIETRUSZKA, MATTHEW DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DANIEL
Last Name:PIETRUSZKA
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 1:5438 S 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1013
Mailing Address - Country:US
Mailing Address - Phone:312-614-2020
Mailing Address - Fax:312-626-5139
Practice Address - Street 1:555 S DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1586
Practice Address - Country:US
Practice Address - Phone:312-614-2020
Practice Address - Fax:312-626-5139
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-29
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist