Provider Demographics
NPI:1932102951
Name:JIMENEZ AGOSTO, JAIME (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:JIMENEZ AGOSTO
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 1:1420 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3107
Mailing Address - Country:US
Mailing Address - Phone:601-264-3937
Mailing Address - Fax:601-264-5930
Practice Address - Street 1:1420 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3107
Practice Address - Country:US
Practice Address - Phone:601-264-3937
Practice Address - Fax:601-264-5930
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12372207W00000X, 207WX0107X, 207WX0108X
TXH8698207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I180024OtherMEDICARE PTAN FOR SOUTHERN EYE PHYSICIAN'S CENTER LLC
MS00115830Medicaid
MS512I180025OtherMEDICARE PTAN FOR SOUTHERN EYE SURGERY CENTER LLC
MS512I180024OtherMEDICARE PTAN FOR SOUTHERN EYE PHYSICIAN'S CENTER LLC
MS512I180024OtherMEDICARE PTAN FOR SOUTHERN EYE PHYSICIAN'S CENTER LLC