Provider Demographics
NPI:1508856725
Name:TRUJILLO, TRACY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:THOMAS
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PORTER DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1524
Mailing Address - Country:US
Mailing Address - Phone:925-838-6511
Mailing Address - Fax:925-838-6544
Practice Address - Street 1:200 PORTER DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1524
Practice Address - Country:US
Practice Address - Phone:925-838-6500
Practice Address - Fax:925-838-6542
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G720640Medicare ID - Type Unspecified
F79794Medicare UPIN