Provider Demographics
NPI:1932241072
Name:JIMENEZ, LITHIA ENID (OD)
Entity Type:Individual
Prefix:DR
First Name:LITHIA
Middle Name:ENID
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 E WEXLEY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4359
Mailing Address - Country:US
Mailing Address - Phone:812-334-2351
Mailing Address - Fax:
Practice Address - Street 1:355 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5002
Practice Address - Country:US
Practice Address - Phone:812-333-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002601B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200970Medicare ID - Type Unspecified
INU94092Medicare UPIN