Provider Demographics
NPI:1477502441
Name:JIMENEZ-DAVILA, LISSETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISSETTE
Middle Name:
Last Name:JIMENEZ-DAVILA
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 1:400 DOMENECH AVE.
Mailing Address - Street 2:SUITE 407
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3704
Mailing Address - Country:US
Mailing Address - Phone:787-754-3300
Mailing Address - Fax:787-754-4966
Practice Address - Street 1:400 DOMENECH AVE.
Practice Address - Street 2:SUITE 407
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3704
Practice Address - Country:US
Practice Address - Phone:787-754-3300
Practice Address - Fax:787-754-4966
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR105272084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF14148Medicare UPIN