Provider Demographics
NPI:1568532596
Name:TRIVEDI, SHRIPRAKASH NANDSHANKAR (MD)
Entity Type:Individual
Prefix:
First Name:SHRIPRAKASH
Middle Name:NANDSHANKAR
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 1:22505 LANDMARK CT STE 210
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6500
Mailing Address - Country:US
Mailing Address - Phone:571-612-6600
Mailing Address - Fax:571-612-6601
Practice Address - Street 1:22505 LANDMARK CT STE 210
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148-6500
Practice Address - Country:US
Practice Address - Phone:571-612-6600
Practice Address - Fax:571-612-6601
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232770207RA0000X
VA0101238017207RA0000X, 207R00000X
NJ25MA07786000207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2606164Medicaid
NY2606164Medicaid
022155I37Medicare PIN