Provider Demographics
NPI:1104936566
Name:MRUZIK, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MRUZIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-874-0008
Mailing Address - Fax:573-875-5350
Practice Address - Street 1:601 BUSINESS LOOP 70 W
Practice Address - Street 2:SUITE 275
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2585
Practice Address - Country:US
Practice Address - Phone:573-874-0008
Practice Address - Fax:573-875-5350
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46300Medicare UPIN
MO006013640Medicare ID - Type Unspecified