Healthcare Provider Details

I. General information

NPI: 1578686390
Provider Name (Legal Business Name): JAIME TRUJILLO-GOMEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 GREENLEAF AVE
WILMETTE IL
60091-2221
US

IV. Provider business mailing address

2612 GREENLEAF AVE
WILMETTE IL
60091-2221
US

V. Phone/Fax

Practice location:
  • Phone: 847-251-0147
  • Fax: 847-251-0371
Mailing address:
  • Phone: 847-251-0147
  • Fax: 847-251-0371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: