MEDICARE: MICHAEL PETRUSKA OD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG001776	PA

General Provider Information

NPI Number	:	1124179494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL PETRUSKA OD PC

Provider Business Mailing Address
First Line	:	4379 EISENHOWER DR
Second Line	:
City	:	BETHLEHEM
State	:	PA
Zip	:	18020-8937
Country	:	US
Telephone Number	:	610-759-0806
Fax Number	:	610-515-1679

Provider Business Practice Location Address
First Line	:	2501 SHEILA LN
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-2041
Country	:	US
Telephone Number	:	804-320-9457
Fax Number	:	804-320-9458

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL PETRUSKA
Credential	:	O.D.
Telephone Number	:	484-223-6930

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	08/22/2020

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