Provider Demographics
NPI:1104870310
Name:MITRUSKA, DARYL SUSAN (DC)
Entity type:Individual
Prefix:DR
First Name:DARYL
Middle Name:SUSAN
Last Name:MITRUSKA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 CONVERY BLVD
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-2584
Mailing Address - Country:US
Mailing Address - Phone:732-324-4300
Mailing Address - Fax:732-324-8211
Practice Address - Street 1:453 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-2960
Practice Address - Country:US
Practice Address - Phone:732-324-4300
Practice Address - Fax:732-324-8211
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04382111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ757243Medicare PIN
NJU48129Medicare UPIN