Provider Demographics
NPI:1093767147
Name:TRUTY, SHARYL J (MD)
Entity Type:Individual
Prefix:
First Name:SHARYL
Middle Name:J
Last Name:TRUTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6259
Mailing Address - Country:US
Mailing Address - Phone:904-930-4774
Mailing Address - Fax:904-647-2476
Practice Address - Street 1:115 PROFESSIONAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6259
Practice Address - Country:US
Practice Address - Phone:904-930-4774
Practice Address - Fax:904-647-2476
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105329Medicaid
FLIM454ABPC30459YMedicare Oscar/Certification
FLH69060Medicare UPIN
FLIM454ABPC30459YMedicare PIN
ILK27627Medicare PIN
ILH69060Medicare UPIN