Provider Demographics
NPI:1568983781
Name:JEFFERSON M TRUPP MD PA
Entity Type:Organization
Organization Name:JEFFERSON M TRUPP MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRUPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-481-1687
Mailing Address - Street 1:2900 S HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-5612
Mailing Address - Country:US
Mailing Address - Phone:850-481-1687
Mailing Address - Fax:850-640-0761
Practice Address - Street 1:2900 S HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-5612
Practice Address - Country:US
Practice Address - Phone:850-481-1687
Practice Address - Fax:850-640-0761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME406822085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty