Provider Demographics
NPI:1811736853
Name:RUIZ, OLIVIA (OD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:RUIZ
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 1:429 E 12TH AVE APT H
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2244
Mailing Address - Country:US
Mailing Address - Phone:317-339-7119
Mailing Address - Fax:
Practice Address - Street 1:1515 6TH ST STE A
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2272
Practice Address - Country:US
Practice Address - Phone:920-499-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007290152W00000X
WI4012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist