Provider Demographics
NPI:1093741100
Name:TRUXILLO, JEROME ANTHONY (PT, OCS)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:ANTHONY
Last Name:TRUXILLO
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 REDSTONE AVE W
Mailing Address - Street 2:SUITE 390
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6428
Mailing Address - Country:US
Mailing Address - Phone:850-683-0077
Mailing Address - Fax:850-683-0099
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:SUITE 390
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-683-0077
Practice Address - Fax:850-683-0099
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY906YOtherBCBSFL GROUP #
FLY2530YMedicare ID - Type UnspecifiedINDIVIDUAL