Provider Demographics
NPI:1285724443
Name:RUZICKA, MATTHEW DAVID (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:RUZICKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-3218
Mailing Address - Country:US
Mailing Address - Phone:937-339-2020
Mailing Address - Fax:937-339-2332
Practice Address - Street 1:4 S MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3218
Practice Address - Country:US
Practice Address - Phone:937-339-2020
Practice Address - Fax:937-339-2332
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 5090 / T 1969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000353804OtherANTHEM
U65866Medicare UPIN
RU4051474Medicare ID - Type Unspecified