Provider Demographics
NPI:1417478629
Name:GIMENEZ, JOHANA BEATRIZ (MD)
Entity Type:Individual
Prefix:
First Name:JOHANA
Middle Name:BEATRIZ
Last Name:GIMENEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOHANA
Other - Middle Name:BEATRIZ
Other - Last Name:GIMENEZ RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10465
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-0465
Mailing Address - Country:US
Mailing Address - Phone:773-883-2350
Mailing Address - Fax:773-883-2351
Practice Address - Street 1:4116 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3028
Practice Address - Country:US
Practice Address - Phone:773-883-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.152253208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.152253OtherMD LICENSE