Provider Demographics
NPI:1598495376
Name:KETAN TRIVEDI MD, PLLC
Entity Type:Organization
Organization Name:KETAN TRIVEDI MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-734-9924
Mailing Address - Street 1:4422 CALDERA CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9057
Mailing Address - Country:US
Mailing Address - Phone:901-734-9924
Mailing Address - Fax:239-315-4915
Practice Address - Street 1:4760 TAMIAMI TRL N STE 24
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-3065
Practice Address - Country:US
Practice Address - Phone:239-331-4870
Practice Address - Fax:239-315-4915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME96812OtherMEDICAL LICENSE