Provider Demographics
NPI:1457353583
Name:TRIVEDI, KETAN K (MD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:K
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 1:2901 TELESTAR CT.
Mailing Address - Street 2:#300
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1263
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:3580 JOSEPH SIEWICK DR STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1764
Practice Address - Country:US
Practice Address - Phone:703-648-3266
Practice Address - Fax:703-648-3264
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055841207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC031748200Medicaid
VA060068844OtherRAILROAD MEDICARE VA #
DC060062810OtherRAILROAD MEDICARE DC#
VA1457353583Medicaid
MD699158100Medicaid
VA005868769Medicaid
VA1457353583Medicaid
DC060062810OtherRAILROAD MEDICARE DC#
VA005868769Medicaid
DC006568C42Medicare PIN
VA005868769Medicaid
DC060062810OtherRAILROAD MEDICARE DC#
VA005873258Medicaid