Provider Demographics
NPI:1871552638
Name:TRUPP, JEFFERSON MASON (MD)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:MASON
Last Name:TRUPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8203 N LAGOON DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32408-5267
Mailing Address - Country:US
Mailing Address - Phone:850-896-0773
Mailing Address - Fax:850-234-9272
Practice Address - Street 1:1410 MCFARLAND BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2459
Practice Address - Country:US
Practice Address - Phone:205-345-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.114792085R0001X
FLME406822085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266076800Medicaid
AL000014577Medicaid
AL000014577Medicaid
C76316Medicare UPIN
FL46706Medicare ID - Type Unspecified