Provider Demographics
NPI:1083713614
Name:JIMENEZ, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
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 15407
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-8607
Mailing Address - Country:US
Mailing Address - Phone:210-612-3244
Mailing Address - Fax:210-637-9034
Practice Address - Street 1:2515 MCCULLOUGH AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3584
Practice Address - Country:US
Practice Address - Phone:210-612-3244
Practice Address - Fax:210-637-9034
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD32832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123609302Medicaid
B75767Medicare UPIN
TX451521ZU0LMedicare PIN
TX123609302Medicaid