Provider Demographics
NPI:1558486050
Name:TRIVAX, BRADLEY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SCOTT
Last Name:TRIVAX
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 COMMACK RD UNIT 204
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5022
Mailing Address - Country:US
Mailing Address - Phone:631-638-4600
Mailing Address - Fax:631-638-4601
Practice Address - Street 1:500 COMMACK RD UNIT 204
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5022
Practice Address - Country:US
Practice Address - Phone:631-638-4600
Practice Address - Fax:631-638-4601
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236257207V00000X
CAA92047207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology