Provider Demographics
NPI:1255466801
Name:JIMENEZ, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:801 N TUSTIN AVE
Mailing Address - Street 2:STE 601
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3610
Mailing Address - Country:US
Mailing Address - Phone:714-565-1077
Mailing Address - Fax:714-565-1086
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:STE 601
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3610
Practice Address - Country:US
Practice Address - Phone:714-565-1077
Practice Address - Fax:714-565-1086
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF76464Medicare UPIN
CAWG75231GMedicare ID - Type Unspecified