Provider Demographics
NPI:1285634113
Name:JIMENEZ, HERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:HERNANDO
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 1:4700 BERWYN HOUSE RD STE 208
Mailing Address - Street 2:COLLEGE PARK
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4719
Mailing Address - Country:US
Mailing Address - Phone:301-220-0150
Mailing Address - Fax:301-220-1032
Practice Address - Street 1:2500 HOSPITAL DRIVE
Practice Address - Street 2:CITY HOSPITAL
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-264-1212
Practice Address - Fax:304-264-0135
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10129207ZN0500X, 207ZP0101X
VA0101022951207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV220021414OtherRAILROAD MEDICARE
WV0101738000Medicaid
E56423Medicare UPIN
WV0101738000Medicaid