Provider Demographics
NPI:1740240258
Name:TRUITT, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:TRUITT
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 1:1528 NORTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1255
Mailing Address - Country:US
Mailing Address - Phone:320-252-0233
Mailing Address - Fax:320-257-1126
Practice Address - Street 1:1528 NORTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1255
Practice Address - Country:US
Practice Address - Phone:320-252-0233
Practice Address - Fax:320-257-1126
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42775207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN023625000Medicaid