Provider Demographics
NPI:1154680932
Name:ROTRUCK, JILL CHRISTIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:CHRISTIE
Last Name:ROTRUCK
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 1:40 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2715
Mailing Address - Country:US
Mailing Address - Phone:203-785-2020
Mailing Address - Fax:
Practice Address - Street 1:40 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-785-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA131444207W00000X
WV390200000X
CT60313207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program