Provider Demographics
NPI:1629074299
Name:TRIVEDI, NIMISHA J (MD)
Entity Type:Individual
Prefix:DR
First Name:NIMISHA
Middle Name:J
Last Name:TRIVEDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3778 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248
Mailing Address - Country:US
Mailing Address - Phone:678-610-6649
Mailing Address - Fax:678-610-6025
Practice Address - Street 1:3778 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248
Practice Address - Country:US
Practice Address - Phone:678-610-6649
Practice Address - Fax:678-610-6025
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2016-09-15
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
GA053715207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA117518856AMedicaid
I01657Medicare UPIN
GA08BBQRDMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER