Provider Demographics
NPI:1396073078
Name:TRUJILLO, LUIS BERNARDO (MA 39379)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:BERNARDO
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:MA 39379
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3402
Mailing Address - Country:US
Mailing Address - Phone:813-307-0933
Mailing Address - Fax:
Practice Address - Street 1:2614 VINEDALE AVE
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-7383
Practice Address - Country:US
Practice Address - Phone:813-719-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA39379261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation