Provider Demographics
NPI:1235252537
Name:TRUDEAU, TY ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:ANTHONY
Last Name:TRUDEAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4549
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32793-4549
Mailing Address - Country:US
Mailing Address - Phone:407-772-2225
Mailing Address - Fax:407-772-0302
Practice Address - Street 1:483 N. SEMORAN BLVD.
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792
Practice Address - Country:US
Practice Address - Phone:407-772-2225
Practice Address - Fax:407-772-0302
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76974Medicare ID - Type Unspecified