Healthcare Provider Details

I. General information

NPI: 1306306014
Provider Name (Legal Business Name): SOPHIE TRUJILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10080 SW INNOVATION WAY STE 201
PORT ST LUCIE FL
34987-2129
US

IV. Provider business mailing address

10080 SW INNOVATION WAY STE 201
PORT ST LUCIE FL
34987-2129
US

V. Phone/Fax

Practice location:
  • Phone: 772-398-1800
  • Fax: 772-398-1820
Mailing address:
  • Phone: 727-398-1800
  • Fax: 727-398-1820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS23635
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: