Provider Demographics
NPI:1093754939
Name:TRUXILLO, RYAN MARK (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MARK
Last Name:TRUXILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 W JUDGE PEREZ DR
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-1734
Mailing Address - Country:US
Mailing Address - Phone:504-304-2800
Mailing Address - Fax:504-826-9650
Practice Address - Street 1:8050 W JUDGE PEREZ DR
Practice Address - Street 2:SUITE 3100
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-1734
Practice Address - Country:US
Practice Address - Phone:504-304-2800
Practice Address - Fax:504-826-9650
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201607174400000X
LAMD201607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2319680Medicaid
255644YJ78OtherPTAN
LA1143570Medicaid
LA1143570Medicaid
LA4N055DS32Medicare PIN