Provider Demographics
NPI:1316456528
Name:MEDEROS TRUJILLO, ORESTES (MD)
Entity type:Individual
Prefix:
First Name:ORESTES
Middle Name:
Last Name:MEDEROS TRUJILLO
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 1:500 SW 145TH AVE APT 230
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6209
Mailing Address - Country:US
Mailing Address - Phone:786-553-0177
Mailing Address - Fax:954-206-0430
Practice Address - Street 1:7000 W 12TH AVE STE 4
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5154
Practice Address - Country:US
Practice Address - Phone:305-587-2812
Practice Address - Fax:305-381-0977
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME156095207R00000X, 208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114329700Medicaid