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General NPI Number Information
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NPI Number | 1124179494
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Entity Type | Organization
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Legal Business Name | MICHAEL PETRUSKA OD PC
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Dates
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Enumeration Date | 01/15/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2501 SHEILA LN
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City | RICHMOND
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State | VA
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Zip | 23225-2041
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Country | US
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Telephone | 804-320-9457
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Fax | 804-320-9458
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Provider Business Mailing Address
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Address Line | 4379 EISENHOWER DR
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City | BETHLEHEM
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State | PA
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Zip | 18020-8937
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Country | US
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Telephone | 610-759-0806
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Fax | 610-515-1679
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL PETRUSKA
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Credential | O.D.
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Telephone | 484-223-6930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OEG001776
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License Number State | PA
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