MEDICARE: DR. MATTHEW DANIEL PIETRUSZKA OD

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	046011095	IL

General Provider Information

NPI Number	:	1679001101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW DANIEL PIETRUSZKA OD

Provider Business Mailing Address
First Line	:	5438 S 74TH AVE
Second Line	:
City	:	SUMMIT
State	:	IL
Zip	:	60501-1013
Country	:	US
Telephone Number	:	312-614-2020
Fax Number	:	312-626-5139

Provider Business Practice Location Address
First Line	:	555 S DEARBORN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1586
Country	:	US
Telephone Number	:	312-614-2020
Fax Number	:	312-626-5139

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2017
Last Update Date	:	12/03/2018

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