Provider Demographics
NPI:1407043433
Name:JOSE LUCIANO FARIAS-JIMENEZ, M.D.,P.A.
Entity Type:Organization
Organization Name:JOSE LUCIANO FARIAS-JIMENEZ, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUCIANO
Authorized Official - Last Name:FARIAS-JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-630-2504
Mailing Address - Street 1:416 LINDBERG AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-2922
Mailing Address - Country:US
Mailing Address - Phone:956-630-4161
Mailing Address - Fax:956-664-1398
Practice Address - Street 1:416 LINDBERG AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2922
Practice Address - Country:US
Practice Address - Phone:956-630-4161
Practice Address - Fax:956-664-1398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198620601Medicaid
TXDO7916OtherRAILROAD MEDICARE
TX0011QCOtherBCBS
I11451Medicare UPIN
TX198620601Medicaid