Provider Demographics
NPI:1659422541
Name:JIMENEZ, JOSELUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSELUIS
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 181
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22038-0181
Mailing Address - Country:US
Mailing Address - Phone:202-460-4442
Mailing Address - Fax:
Practice Address - Street 1:19504 AMARANTH DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1210
Practice Address - Country:US
Practice Address - Phone:301-428-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD 0059207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH06000Medicare UPIN