Provider Demographics
NPI:1891734547
Name:SHIMANEK, JEAN (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:SHIMANEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HOSPITAL LP NE
Mailing Address - Street 2:STE 214
Mailing Address - City:ALBUQ
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2128
Mailing Address - Country:US
Mailing Address - Phone:505-883-6600
Mailing Address - Fax:505-883-0023
Practice Address - Street 1:101 HOSPITAL LP NE
Practice Address - Street 2:STE 214
Practice Address - City:ALBUQ
Practice Address - State:NM
Practice Address - Zip Code:87109-2128
Practice Address - Country:US
Practice Address - Phone:505-883-6600
Practice Address - Fax:505-883-0023
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM913072086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2086S0122XMedicaid
NM741440546305OtherTRIWEST
NME2086Medicaid
NM$$$$$$$$$MMedicare PIN
A16106Medicare UPIN