Basic Information
| Provider Information | |||||||||
| NPI: | 1588747885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRIVEDI | ||||||||
| FirstName: | KETAN | ||||||||
| MiddleName: | HASMUKHRAI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341193900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393484400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6101 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341193900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393484400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME 96812 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 276994800 | 05 | FL | MEDICAID |