Provider Demographics
NPI:1124216742
Name:CARLOS C. JIMENEZ MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CARLOS C. JIMENEZ MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:C
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-845-1331
Mailing Address - Street 1:1000 WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1750
Mailing Address - Country:US
Mailing Address - Phone:304-845-1331
Mailing Address - Fax:304-845-9152
Practice Address - Street 1:1000 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1750
Practice Address - Country:US
Practice Address - Phone:304-845-1331
Practice Address - Fax:304-845-9152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0076414000Medicaid
WV0363883Medicare PIN
WV0076414000Medicaid