Provider Demographics
NPI:1528029352
Name:JIMENEZ, DANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name: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 1:2720 STONE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3734
Mailing Address - Country:US
Mailing Address - Phone:712-279-3789
Mailing Address - Fax:712-279-3613
Practice Address - Street 1:2720 STONE PARK BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3734
Practice Address - Country:US
Practice Address - Phone:712-279-3789
Practice Address - Fax:712-279-3613
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21344207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00142603OtherRR MEDICARE NUMBER
IAP00142603OtherRR MEDICARE NUMBER
C43209Medicare UPIN