Provider Demographics
NPI:1912941774
Name:JIMENEZ, MITZI T (MD)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:T
Last Name:JIMENEZ
Suffix:
Gender:F
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:PO BOX 231233
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77223-1233
Mailing Address - Country:US
Mailing Address - Phone:713-923-6333
Mailing Address - Fax:713-923-4197
Practice Address - Street 1:910 S WAYSIDE DR STE 150
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77023-3430
Practice Address - Country:US
Practice Address - Phone:713-923-6333
Practice Address - Fax:713-923-4197
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123701805Medicaid
TX00NT73Medicare PIN
TXE86090Medicare UPIN