Healthcare Provider Details

I. General information

NPI: 1285724443
Provider Name (Legal Business Name): MATTHEW DAVID RUZICKA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 S MARKET ST
TROY OH
45373-3218
US

IV. Provider business mailing address

4 S MARKET ST
TROY OH
45373-3218
US

V. Phone/Fax

Practice location:
  • Phone: 937-339-2020
  • Fax: 937-339-2332
Mailing address:
  • Phone: 937-339-2020
  • Fax: 937-339-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOH 5090 / T 1969
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: