Provider Demographics
NPI:1295761898
Name:TRUITT, JOHN SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SAMUEL
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 1:9787 TURKEY TRACK
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615
Mailing Address - Country:US
Mailing Address - Phone:520-378-4029
Mailing Address - Fax:520-458-1001
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-624-8738
Practice Address - Fax:575-624-8758
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ217492085R0001X
TXJ55012085R0001X
NM86-1362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D17454Medicare UPIN