Provider Demographics
NPI:1619994563
Name:JIMENEZ, TEODORO (MD)
Entity Type:Individual
Prefix:
First Name:TEODORO
Middle Name:
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:PO BOX 1650
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44309-1650
Mailing Address - Country:US
Mailing Address - Phone:330-864-8900
Mailing Address - Fax:330-869-8924
Practice Address - Street 1:217 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1823
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:859-335-9072
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11737207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3000130OtherBWC
TN4401035Medicaid
WV0055978000Medicaid
KYP00212626OtherRR-MEDICARE
KY000000384514OtherANTHEM
KYD49562Medicare UPIN
WV3000130OtherBWC