Provider Demographics
NPI:1871534552
Name:TRIVICH, KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:TRIVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 S BROOKHURST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3563
Mailing Address - Country:US
Mailing Address - Phone:714-991-5700
Mailing Address - Fax:714-991-5800
Practice Address - Street 1:631 S BROOKHURST ST STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3563
Practice Address - Country:US
Practice Address - Phone:714-991-5700
Practice Address - Fax:714-991-5800
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43731207R00000X
CA43731207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A49450Medicaid
CACG450YMedicare PIN
A49445Medicare UPIN
CAWG43731MMedicare PIN
CA00A49450Medicaid