Provider Demographics
NPI:1033145065
Name:JIMENEZ, SANTIAGO A (MD)
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:A
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 1:8734 LEE VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8022
Mailing Address - Country:US
Mailing Address - Phone:407-910-2340
Mailing Address - Fax:407-237-0944
Practice Address - Street 1:8734 LEE VISTA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-8022
Practice Address - Country:US
Practice Address - Phone:407-910-2340
Practice Address - Fax:407-237-0944
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65074208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373964300Medicaid
FL373964300Medicaid
FLF04120Medicare UPIN