Provider Demographics
NPI:1821042094
Name:TRUJILLO, LUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
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 1:2510 ABBOTT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-5006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 QUARTER ST
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1959
Practice Address - Country:US
Practice Address - Phone:989-426-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI071407207PE0004X, 208M00000X
MI4301071407207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0106510712OtherBLUE SHIELD
MI1821042094Medicaid
MI4769870Medicaid
MI0F71000OtherBCBS
MILT071407OtherBLUE CROSS BLUE SHIELD
MI0F76001Medicare PIN
MILT071407OtherBLUE CROSS BLUE SHIELD
MIP51030009Medicare UPIN
MI1821042094Medicaid
MIE43278Medicare UPIN
MIM60660311Medicare PIN