Provider Demographics
NPI:1437142403
Name:JIMENEZ BERROA, LUIS E (MD)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:E
Last Name:JIMENEZ BERROA
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:PO BOX 8731
Mailing Address - Street 2:PLAZA CAROLINA STATION
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00988-8731
Mailing Address - Country:US
Mailing Address - Phone:787-721-4836
Mailing Address - Fax:787-721-8448
Practice Address - Street 1:SAN JUAN CITY HOSPITAL
Practice Address - Street 2:MEDICAL CENTER
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936
Practice Address - Country:US
Practice Address - Phone:787-766-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11226174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR83634Medicare ID - Type Unspecified