Provider Demographics
NPI:1639192057
Name:DANIEL JIMENEZ, MD, INC
Entity Type:Organization
Organization Name:DANIEL JIMENEZ, MD, INC
Other - Org Name:JIMENEZ MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-565-1077
Mailing Address - Street 1:801 N TUSTIN AVE
Mailing Address - Street 2:STE 601
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3610
Mailing Address - Country:US
Mailing Address - Phone:714-565-1077
Mailing Address - Fax:714-565-1086
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:STE 601
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3610
Practice Address - Country:US
Practice Address - Phone:714-565-1077
Practice Address - Fax:714-565-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF76464Medicare UPIN
CAW18056Medicare ID - Type UnspecifiedGROUP PROVIDER #