Provider Demographics
NPI:1578655494
Name:JIMENEZ, MARCUS A (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:A
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 1:2510 N GLENDALE DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-432-7654
Mailing Address - Fax:260-432-7709
Practice Address - Street 1:2510 N GLENDALE DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-432-7654
Practice Address - Fax:260-432-7709
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043881A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
F45857Medicare UPIN
IN216680Medicare ID - Type Unspecified