Provider Demographics
NPI:1689249328
Name:TRIVEDI, KRUNAL
Entity type:Individual
Prefix:
First Name:KRUNAL
Middle Name:
Last Name:TRIVEDI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 DAVEY DR
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2174
Mailing Address - Country:US
Mailing Address - Phone:331-302-7878
Mailing Address - Fax:
Practice Address - Street 1:111 CENTRAL AVE DEPT D7
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:973-877-5465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA12134200207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine