Provider Demographics
NPI:1922093806
Name:JIMA, BOGALE (MD)
Entity Type:Individual
Prefix:MR
First Name:BOGALE
Middle Name:
Last Name:JIMA
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 1:13861 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2091
Mailing Address - Country:US
Mailing Address - Phone:804-739-0910
Mailing Address - Fax:804-739-2763
Practice Address - Street 1:13861 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2091
Practice Address - Country:US
Practice Address - Phone:804-739-0910
Practice Address - Fax:804-739-2763
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5631408Medicaid
VA541717999OtherTAX ID
VA541717999OtherTAX ID
VA080119453Medicare PIN
VA5631408Medicaid
VA018252P46Medicare PIN