Healthcare Provider Details

I. General information

NPI: 1306045596
Provider Name (Legal Business Name): MITESH TRIVEDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST # TE-2
NEW HAVEN CT
06510-3206
US

IV. Provider business mailing address

101 N PLAINS INDUSTRIAL RD
WALLINGFORD CT
06492-2360
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-5253
  • Fax:
Mailing address:
  • Phone: 203-949-2700
  • Fax: 203-949-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC7-0004007
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC1-0009080
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number050778
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT191109
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: