Provider Demographics
NPI:1164445763
Name:JIMENEZ, SERGIO A (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:A
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 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 740
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 740
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-6680
Practice Address - Fax:215-503-3333
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034713L207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2264200Medicaid
PA000662472Medicaid
NJ2264200Medicaid