Provider Demographics
NPI:1093052433
Name:DR JOSE M MENDEZJIMINIAN CSP
Entity Type:Organization
Organization Name:DR JOSE M MENDEZJIMINIAN CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MENDEZ JIMINIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-863-4714
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-2010
Mailing Address - Country:US
Mailing Address - Phone:787-863-4714
Mailing Address - Fax:787-655-2301
Practice Address - Street 1:353 AVE GENERAL VALERO
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-4843
Practice Address - Country:US
Practice Address - Phone:787-863-4714
Practice Address - Fax:787-655-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12631261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH81709Medicare UPIN