Provider Demographics
NPI:1649267923
Name:JIMENEZ, RAUL A (MD)
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:A
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 1:2055 LITTLE ROAD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655
Mailing Address - Country:US
Mailing Address - Phone:727-862-3202
Mailing Address - Fax:727-862-2182
Practice Address - Street 1:14100 FIVAY RD
Practice Address - Street 2:STE 310
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7180
Practice Address - Country:US
Practice Address - Phone:727-862-3202
Practice Address - Fax:727-862-2182
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62750207RC0001X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
72434OtherAVMED
FL268702000Medicaid
82440OtherBCBS
F39291Medicare UPIN
FLU3145ZMedicare ID - Type Unspecified