Provider Demographics
NPI:1124341763
Name:TROUT, TREVOR JAMES (IDC)
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:JAMES
Last Name:TROUT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 OLD HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:MC HENRY
Mailing Address - State:MS
Mailing Address - Zip Code:39561-6176
Mailing Address - Country:US
Mailing Address - Phone:239-989-8748
Mailing Address - Fax:
Practice Address - Street 1:2603 LOWER GAINESVILLE RD
Practice Address - Street 2:
Practice Address - City:STENNIS SPACE CENTER
Practice Address - State:MS
Practice Address - Zip Code:39529-0001
Practice Address - Country:US
Practice Address - Phone:228-813-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman