Provider Demographics
NPI:1063462190
Name:JIMENEZ, RICARDO ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:ENRIQUE
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 1:3637 MISSION AVE
Mailing Address - Street 2:BLGD A STE 3
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2946
Mailing Address - Country:US
Mailing Address - Phone:916-863-1496
Mailing Address - Fax:916-863-1498
Practice Address - Street 1:3637 MISSION AVE
Practice Address - Street 2:BLDG A STE 3
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2946
Practice Address - Country:US
Practice Address - Phone:916-863-1496
Practice Address - Fax:916-863-1498
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068683L207ZP0102X
CAA73866207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014788620001Medicaid
CA00A738660Medicaid
CA00A738660Medicaid
PA099174Medicare ID - Type Unspecified
PA1014788620001Medicaid