Provider Demographics
NPI:1841388378
Name:JIMBO, MASAHITO (MD)
Entity Type:Individual
Prefix:DR
First Name:MASAHITO
Middle Name:
Last Name:JIMBO
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 1:1919 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7246
Mailing Address - Country:US
Mailing Address - Phone:312-413-8784
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF ILLINOIS HOSPITAL
Practice Address - Street 2:1740 W. TAYLOR STREET
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036156220207Q00000X
MI4301084676207RN0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4642137Medicaid
MIG32861Medicare UPIN
MI0H17630106Medicare ID - Type Unspecified