Provider Demographics
NPI:1649204751
Name:JIMENEZ, MIGUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
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 1:3280 POINTE PKWY STE 2550
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3473
Mailing Address - Country:US
Mailing Address - Phone:877-877-7411
Mailing Address - Fax:877-877-7411
Practice Address - Street 1:3903 S COBB DR SE
Practice Address - Street 2:SUITE 105
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6342
Practice Address - Country:US
Practice Address - Phone:678-838-6600
Practice Address - Fax:770-438-1477
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52966207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA615972752BMedicaid
GA52062173008OtherBCBS AUSTELL ID
GA805775515AMedicaid
GA52062173007OtherBCBS CARTERSVILLE ID
GA615972752AMedicaid
GA52062173007OtherBCBS CARTERSVILLE ID
GAG11962Medicare UPIN
GA52062173008OtherBCBS AUSTELL ID