Provider Demographics
NPI:1487925442
Name:MICHAEL A COLARUSSO, OD, PC
Entity type:Organization
Organization Name:MICHAEL A COLARUSSO, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLARUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-659-2711
Mailing Address - Street 1:1157 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3310
Mailing Address - Country:US
Mailing Address - Phone:765-659-2711
Mailing Address - Fax:765-654-6322
Practice Address - Street 1:1157 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3310
Practice Address - Country:US
Practice Address - Phone:765-659-2711
Practice Address - Fax:765-654-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-24
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002797B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6685540001Medicare NSC
INDS3770Medicare PIN
INM100062915Medicare PIN
INU65345Medicare UPIN
IN6685540001Medicare PIN