Provider Demographics
NPI:1063670487
Name:PIMIENTO, JOSE MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:MARIO
Last Name:PIMIENTO
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 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-4673
Mailing Address - Fax:813-745-5952
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-4673
Practice Address - Fax:813-745-5952
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101914208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program