Provider Demographics
NPI:1356368864
Name:PIETRUSIK, MICHAEL J (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PIETRUSIK
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 1:3277 SOUTH PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-3527
Mailing Address - Country:US
Mailing Address - Phone:716-822-3411
Mailing Address - Fax:716-822-0215
Practice Address - Street 1:3277 SOUTH PARK AVENUE
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-3527
Practice Address - Country:US
Practice Address - Phone:716-822-3411
Practice Address - Fax:716-822-0215
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO36341213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00845978Medicaid
U00115Medicare UPIN
NY003721Medicare ID - Type Unspecified