Provider Demographics
NPI:1104038124
Name:TRUITT, ROBERT ELLIS JR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLIS
Last Name:TRUITT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3411
Mailing Address - Country:US
Mailing Address - Phone:619-253-6741
Mailing Address - Fax:
Practice Address - Street 1:2950 FERN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3411
Practice Address - Country:US
Practice Address - Phone:619-253-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF 727562471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography