Provider Demographics
NPI:1174566095
Name:TRIVAX, JUSTIN ELIJAH (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ELIJAH
Last Name:TRIVAX
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:29992 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:248-851-1430
Mailing Address - Fax:248-851-5182
Practice Address - Street 1:31500 TELEGRAPH RD
Practice Address - Street 2:SUITE 115
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4367
Practice Address - Country:US
Practice Address - Phone:248-594-4913
Practice Address - Fax:248-594-4928
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-12-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301081886207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174566095Medicaid
MI700H273300OtherBLUE SHIELD
MI1174566095Medicaid