Provider Demographics
NPI:1063411288
Name:TRIVLIS, MARYANN Z (DPM)
Entity type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:Z
Last Name:TRIVLIS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BEACH 138TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1337
Mailing Address - Country:US
Mailing Address - Phone:718-945-0770
Mailing Address - Fax:718-945-7938
Practice Address - Street 1:131 BEACH 138TH ST
Practice Address - Street 2:
Practice Address - City:BELLE HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11694-1337
Practice Address - Country:US
Practice Address - Phone:718-945-0770
Practice Address - Fax:718-945-7938
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003929-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00909839Medicaid
NYP40841Medicare PIN
NY00909839Medicaid