Provider Demographics
NPI:1689611832
Name:RUZICKA, PETR O (MD)
Entity Type:Individual
Prefix:DR
First Name:PETR
Middle Name:O
Last Name:RUZICKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1432 S, DOBSON
Mailing Address - Street 2:SUITE 403
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202
Mailing Address - Country:US
Mailing Address - Phone:480-412-7400
Mailing Address - Fax:480-412-7500
Practice Address - Street 1:1432 S, DOBSON
Practice Address - Street 2:SUITE 403
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-412-7400
Practice Address - Fax:480-412-7500
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
173000000X
AZ410042086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C54951Medicare UPIN