Provider Demographics
NPI:1619268463
Name:JIMENEZ, ANGELA C (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:C
Other - Last Name:GRANADOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5880 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9447
Mailing Address - Country:US
Mailing Address - Phone:928-425-3261
Mailing Address - Fax:928-425-3859
Practice Address - Street 1:5880 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9447
Practice Address - Country:US
Practice Address - Phone:928-425-3261
Practice Address - Fax:928-425-3859
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115118208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841217866Medicaid
CAFHC03884FMedicaid
CAFHC70593FMedicaid
CA1841217866OtherCORPORATE NPI NUMBER
CAFHC71031FMedicaid
CA551903Medicare Oscar/Certification
CAFHC03884FMedicaid
CA1841217866Medicaid
CAW1508AMedicare PIN