Provider Demographics
NPI:1407931496
Name:BARA-JIMENEZ, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BARA-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 1:11119 ROCKVILLE PIKE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3143
Mailing Address - Country:US
Mailing Address - Phone:301-816-9000
Mailing Address - Fax:301-816-0295
Practice Address - Street 1:10901 CONNECTICUT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1645
Practice Address - Country:US
Practice Address - Phone:240-221-8052
Practice Address - Fax:240-221-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD414111300Medicaid
MDI71322Medicare UPIN
MD414111300Medicaid