Provider Demographics
NPI:1003104423
Name:TRUJILLO, DALE MICHAEL (NP)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:MICHAEL
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:DALE
Other - Middle Name:MICHAEL
Other - Last Name:BUCEK TRUJILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009664363LF0000X
CANP95009664363L00000X
CA18136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist