Provider Demographics
NPI:1649223140
Name:TROUT, TERE E (MD)
Entity Type:Individual
Prefix:
First Name:TERE
Middle Name:E
Last Name:TROUT
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 1:7777 ALVARADO RD
Mailing Address - Street 2:#108
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-460-2770
Mailing Address - Fax:619-460-2774
Practice Address - Street 1:8881 FLETCHER PARKWAY
Practice Address - Street 2:#102
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-461-1830
Practice Address - Fax:619-797-1484
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG702762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G702760OtherBLUE SHIELD PIN
CA00G702760Medicaid
CA00G702760OtherBLUE SHIELD PIN
F59592Medicare UPIN
CA00G702760Medicaid
WG702760Medicare PIN
CAF59592Medicare UPIN
CA300030467Medicare PIN