Provider Demographics
NPI:1679687933
Name:TRIVEDI, JITENDRA (MD)
Entity Type:Individual
Prefix:
First Name:JITENDRA
Middle Name:
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 1:4218 LINCOLNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2156
Mailing Address - Country:US
Mailing Address - Phone:618-899-3600
Mailing Address - Fax:618-241-4810
Practice Address - Street 1:4218 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2156
Practice Address - Country:US
Practice Address - Phone:618-899-3600
Practice Address - Fax:618-241-4810
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057566207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057566Medicaid
ILC45159Medicare UPIN