Provider Demographics
NPI:1184731291
Name:TRIVEDI, RAJESH M (MD)
Entity type:Individual
Prefix:
First Name:RAJESH
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-338-1123
Mailing Address - Fax:
Practice Address - Street 1:205 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5312
Practice Address - Country:US
Practice Address - Phone:262-338-1123
Practice Address - Fax:262-338-7684
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3248100Medicaid
G81963Medicare UPIN
WI3248100Medicaid
171000021Medicare ID - Type UnspecifiedMEDICARE PROVIDER
WI462364800Medicare PIN