Provider Demographics
NPI:1295837086
Name:JIMENEZ, THERESITA G (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESITA
Middle Name:G
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 RAY WEILAND DR
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-3252
Mailing Address - Country:US
Mailing Address - Phone:225-775-8500
Mailing Address - Fax:225-775-0289
Practice Address - Street 1:2402 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-2322
Practice Address - Country:US
Practice Address - Phone:225-771-1510
Practice Address - Fax:225-771-1520
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL014945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1335649Medicaid
LA52949Medicare ID - Type Unspecified
LAB64264Medicare UPIN