Basic Information
| Provider Information | |||||||||
| NPI: | 1699848382 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRUJILLO | ||||||||
| FirstName: | DAX | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 EVERGREEN LN | ||||||||
| Address2: | B | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376977 | ||||||||
| FaxNumber: | 9285379581 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 EVERGREEN LN | ||||||||
| Address2: | B | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376977 | ||||||||
| FaxNumber: | 9285379581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 31549 | AZ | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0000X | 31549 | AZ | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 934613 | 05 | AZ | MEDICAID |