Provider Demographics
NPI:1912380262
Name:LITHIA E. JIMENEZ,OD, LLC
Entity Type:Organization
Organization Name:LITHIA E. JIMENEZ,OD, LLC
Other - Org Name:LANDMARK EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LITHIA
Authorized Official - Middle Name:ENID
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-333-4220
Mailing Address - Street 1:355 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5002
Mailing Address - Country:US
Mailing Address - Phone:812-333-4220
Mailing Address - Fax:812-333-4211
Practice Address - Street 1:355 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5002
Practice Address - Country:US
Practice Address - Phone:812-333-4220
Practice Address - Fax:812-333-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002601B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200970Medicare PIN