Provider Demographics
NPI:1093498230
Name:TRIDENT MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:TRIDENT MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHETARPAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:484-557-9511
Mailing Address - Street 1:14050 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-5335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18564 US HIGHWAY 18 STE 103&104
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2312
Practice Address - Country:US
Practice Address - Phone:760-242-9262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty