Provider Demographics
NPI:1568552628
Name:JIMENEZ, SHANNON R (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:R
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 S LOOP 336 W
Mailing Address - Street 2:STE 200
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3320
Mailing Address - Country:US
Mailing Address - Phone:936-525-3600
Mailing Address - Fax:936-525-3624
Practice Address - Street 1:2600 US HIGHWAY 70 WEST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530
Practice Address - Country:US
Practice Address - Phone:919-735-2478
Practice Address - Fax:919-739-4809
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900553207Q00000X
TXS4847207Q00000X
IA9900553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790150CMedicaid
NC0150COtherBLUE CROSS GROUP #
NC891215KMedicaid
NC1215KOtherBLUE CROSS INDIVIDUAL
NC891215KMedicaid
2400860Medicare PIN
NC0150COtherBLUE CROSS GROUP #
G95748Medicare UPIN
NC2316260Medicare ID - Type UnspecifiedGROUP #