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
State | License ID | Taxonomies |
---|---|---|
FL | ME91242 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 036105329 | Medicaid | |
FL | IM454ABPC30459Y | Medicare Oscar/Certification | |
FL | H69060 | Medicare UPIN | |
FL | IM454ABPC30459Y | Medicare PIN | |
IL | K27627 | Medicare PIN | |
IL | H69060 | Medicare UPIN |