Provider Demographics
NPI:1205967569
Name:TRIVEDI, KETAN M (MD)
Entity type:Individual
Prefix:
First Name:KETAN
Middle Name:M
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 1:1441 N BECKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1201
Mailing Address - Country:US
Mailing Address - Phone:214-942-5733
Mailing Address - Fax:214-942-6115
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-942-5733
Practice Address - Fax:214-942-6115
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044835207P00000X
TXM6430207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188491801Medicaid
TXP00604902OtherRR MEDICARE
TX188491802Medicaid
TXP00425512OtherRR MEDICARE
TX8AB540OtherBCBS
TX8G4706OtherBCBS
TX8J6424OtherMEDICARE
TX8J6424OtherMEDICARE