Provider Demographics
NPI:1306045596
Name:TRIVEDI, MITESH (MD)
Entity Type:Individual
Prefix:
First Name:MITESH
Middle Name:
Last Name:TRIVEDI
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 1:101 N PLAINS INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2360
Mailing Address - Country:US
Mailing Address - Phone:203-949-2700
Mailing Address - Fax:203-949-2712
Practice Address - Street 1:333 CEDAR ST # TE-2
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-785-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC7-00040072085R0202X
DEC1-00090802085R0202X
CT0507782085R0202X
PAMT191109390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program