Provider Demographics
NPI:1649705567
Name:MAR, JIMMIE (DO)
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:
Last Name:MAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-1305
Mailing Address - Country:US
Mailing Address - Phone:408-436-3300
Mailing Address - Fax:
Practice Address - Street 1:1721 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1305
Practice Address - Country:US
Practice Address - Phone:408-436-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305596207R00000X
390200000X
CA20A20119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program