Provider Demographics
NPI:1073512042
Name:JIMENEZ, EDGAR JOHN (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:JOHN
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:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-6282
Mailing Address - Fax:828-687-6285
Practice Address - Street 1:80 DOCTORS DR
Practice Address - Street 2:SUITE 2
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-7290
Practice Address - Country:US
Practice Address - Phone:828-654-6001
Practice Address - Fax:828-654-6007
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31307207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133KHMedicaid
NCC84732Medicare UPIN
NC89133KHMedicaid