Provider Demographics
NPI:1780676148
Name:GIMENEZ, ALICIA SUZANNA (MD)
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:SUZANNA
Last Name:GIMENEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:R.
Other - Middle Name:ALLEN
Other - Last Name:LABERGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1519
Mailing Address - Country:US
Mailing Address - Phone:509-493-2133
Mailing Address - Fax:509-493-9538
Practice Address - Street 1:212 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672
Practice Address - Country:US
Practice Address - Phone:509-493-2133
Practice Address - Fax:509-493-9538
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033032207Q00000X
ORMD20959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8194987Medicaid
WA503836Medicare Oscar/Certification
WAG27895Medicare UPIN
WA000680913Medicare PIN
WA8194987Medicaid