Provider Demographics
NPI:1861400715
Name:JIMENEZ, JUAN R (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:R
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CALLE IRIS
Mailing Address - Street 2:URB BUENAVENTURA
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-1269
Mailing Address - Country:US
Mailing Address - Phone:787-254-3925
Mailing Address - Fax:787-254-3925
Practice Address - Street 1:48 CALLE HENNA
Practice Address - Street 2:URB EL CIBAO
Practice Address - City:COBO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623
Practice Address - Country:US
Practice Address - Phone:787-254-3925
Practice Address - Fax:787-254-3925
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13535208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
203668OtherPREFERED HEALTH
100317OtherCRUZ AZUL
20701JIOtherTRIPLE S
7874OtherINTERNATIONAL MEDICAL CAR
PE4244OtherPANAMERICAN