Provider Demographics
NPI:1619901774
Name:TRUITT, THOMAS R (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:TRUITT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8666
Mailing Address - Country:US
Mailing Address - Phone:937-644-8637
Mailing Address - Fax:937-644-8653
Practice Address - Street 1:1001 W FIFTH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-644-8637
Practice Address - Fax:937-644-8653
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3642152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0492980Medicaid
OH0526762Medicare PIN
OH0492980Medicaid