Provider Demographics
NPI:1851481022
Name:MATTHEW D RUZICKA OD LLC
Entity Type:Organization
Organization Name:MATTHEW D RUZICKA OD LLC
Other - Org Name:INSIGHTFUL EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RUZICKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-339-2020
Mailing Address - Street 1:4 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-3218
Mailing Address - Country:US
Mailing Address - Phone:937-339-2020
Mailing Address - Fax:937-339-2332
Practice Address - Street 1:4 S MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3218
Practice Address - Country:US
Practice Address - Phone:937-339-2020
Practice Address - Fax:937-339-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 5090 / T1969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9350111OtherPTAN
9350111OtherPTAN