Provider Demographics
NPI:1033931589
Name:TRIVILEGIO, THADEO GONZALES (ASCPI,CM)
Entity type:Individual
Prefix:MR
First Name:THADEO
Middle Name:GONZALES
Last Name:TRIVILEGIO
Suffix:
Gender:M
Credentials:ASCPI,CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E CRESCENT DR APT 1
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77864-3076
Mailing Address - Country:US
Mailing Address - Phone:936-436-3238
Mailing Address - Fax:
Practice Address - Street 1:100 W CROSS ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864-2432
Practice Address - Country:US
Practice Address - Phone:936-349-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25560204207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine