Provider Demographics
NPI:1639287121
Name:JIMENEZ, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
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 2494
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-2494
Mailing Address - Country:US
Mailing Address - Phone:787-854-5828
Mailing Address - Fax:
Practice Address - Street 1:3 CALLE C11
Practice Address - Street 2:URB FLAMBOYAN
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-5828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12343174400000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H55604Medicare UPIN
PR89747Medicare ID - Type Unspecified