Provider Demographics
NPI:1134410079
Name:TRUJILLO, REGLA (CRT)
Entity type:Individual
Prefix:MRS
First Name:REGLA
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11422 SW 73RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-2692
Mailing Address - Country:US
Mailing Address - Phone:786-457-7784
Mailing Address - Fax:786-360-4310
Practice Address - Street 1:7282 SW 114TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-2607
Practice Address - Country:US
Practice Address - Phone:786-457-7784
Practice Address - Fax:786-360-4310
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT 58464247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCRT 58464OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF QUALITY ASSURANCE