Provider Demographics
NPI:1588747885
Name:TRIVEDI, KETAN HASMUKHRAI (MD)
Entity type:Individual
Prefix:
First Name:KETAN
Middle Name:HASMUKHRAI
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 1:4513 EXECUTIVE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9033
Mailing Address - Country:US
Mailing Address - Phone:239-624-8130
Mailing Address - Fax:239-624-0831
Practice Address - Street 1:4513 EXECUTIVE DR STE 201
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-9033
Practice Address - Country:US
Practice Address - Phone:239-624-8130
Practice Address - Fax:239-624-0831
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68351OtherFL BLUE
FL119825500Medicaid