Healthcare Provider Details

I. General information

NPI: 1689916975
Provider Name (Legal Business Name): KUSH HARSHAVARDHAN TRIPATHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 WILES RD STE 201
COCONUT CREEK FL
33073
US

IV. Provider business mailing address

4515 WILES RD STE 201
COCONUT CREEK FL
33073-3414
US

V. Phone/Fax

Practice location:
  • Phone: 954-943-1133
  • Fax:
Mailing address:
  • Phone: 954-943-1133
  • Fax: 954-532-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125064824
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number136066
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number136066
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: