Provider Demographics
NPI:1619208980
Name:JIMENEZ VEGA, JOSE MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:JIMENEZ VEGA
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 1:9680 TAMARACK RD STE 130
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9680 TAMARACK RD STE 130
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2623
Practice Address - Country:US
Practice Address - Phone:651-265-7575
Practice Address - Fax:651-265-7580
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011087452080P0205X
MN705302080P0205X
MN72204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN390200000XOtherSTUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM