Provider Demographics
NPI:1528000882
Name:TRIVIKRAM, AJITKUMAR TAMPI (MD)
Entity Type:Individual
Prefix:
First Name:AJITKUMAR
Middle Name:TAMPI
Last Name:TRIVIKRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AJIT
Other - Middle Name:
Other - Last Name:TRIVIKRAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:151 BUFFALO AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14303-1243
Mailing Address - Country:US
Mailing Address - Phone:716-282-0400
Mailing Address - Fax:716-284-8085
Practice Address - Street 1:151 BUFFALO AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14303-1243
Practice Address - Country:US
Practice Address - Phone:716-282-0400
Practice Address - Fax:716-284-8085
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010180201OtherUNIVERA
NY5066883OtherBLUE CROSS BLUE SHIELD
NY3100688OtherINDEPENDANT HEALTH
NY00603085Medicaid
NY00010180201OtherUNIVERA
NY00603085Medicaid