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General NPI Number Information
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NPI Number | 1679001101
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Entity Type | Individual
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Provider Name | MATTHEW DANIEL PIETRUSZKA OD
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Gender | Male
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Dates
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Enumeration Date | 05/29/2017
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Last Update Date | 12/03/2018
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Provider Practice Location Address
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Address Line | 555 S DEARBORN ST
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City | CHICAGO
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State | IL
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Zip | 60605-1586
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Country | US
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Telephone | 312-614-2020
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Fax | 312-626-5139
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Provider Business Mailing Address
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Address Line | 5438 S 74TH AVE
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City | SUMMIT
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State | IL
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Zip | 60501-1013
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Country | US
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Telephone | 312-614-2020
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Fax | 312-626-5139
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 046011095
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License Number State | IL
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