Healthcare Provider Details

I. General information

NPI: 1295761898
Provider Name (Legal Business Name): JOHN SAMUEL TRUITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

9787 TURKEY TRACK
HEREFORD AZ
85615
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-8738
  • Fax: 575-624-8758
Mailing address:
  • Phone: 520-378-4029
  • Fax: 520-458-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number21749
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberJ5501
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number86-136
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: