Provider Demographics
NPI:1184788085
Name:COLARUSSO, MICHAEL A (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:COLARUSSO
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 1:1157 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3310
Mailing Address - Country:US
Mailing Address - Phone:765-659-2711
Mailing Address - Fax:765-654-6322
Practice Address - Street 1:1157 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3310
Practice Address - Country:US
Practice Address - Phone:765-659-2711
Practice Address - Fax:765-654-6322
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6685540001Medicare NSC
INM400062929Medicare PIN
INU65345Medicare UPIN