Provider Demographics
NPI:1679766331
Name:JIMENEZ, MICHAEL ANGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANGEL
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 1:1064 DELAWARE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-2509
Mailing Address - Country:US
Mailing Address - Phone:310-435-4140
Mailing Address - Fax:
Practice Address - Street 1:1064 DELAWARE AVE
Practice Address - Street 2:APT 2
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-2509
Practice Address - Country:US
Practice Address - Phone:310-435-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT189479208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery