Healthcare Provider Details

I. General information

NPI: 1043246861
Provider Name (Legal Business Name): DIVYANG J TRIVEDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042
US

IV. Provider business mailing address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-4289
  • Fax: 703-780-9487
Mailing address:
  • Phone: 703-776-4289
  • Fax: 703-780-9487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101045180
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101045180
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number0101045180
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0101045180
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number0101045180
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: