Provider Demographics
NPI:1457401341
Name:RUSZCZYK, ISABELLE AGATHA (OD)
Entity type:Individual
Prefix:DR
First Name:ISABELLE
Middle Name:AGATHA
Last Name:RUSZCZYK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12922 NW 22ND MNR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2539
Mailing Address - Country:US
Mailing Address - Phone:954-435-7753
Mailing Address - Fax:
Practice Address - Street 1:15915 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1201
Practice Address - Country:US
Practice Address - Phone:954-438-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC002716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20495Medicare ID - Type Unspecified