Provider Demographics
NPI:1952397119
Name:JIMENEZ, DORIAN LOUIS (DPM)
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:LOUIS
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 HWY 114 SUITE 150
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-3084
Mailing Address - Country:US
Mailing Address - Phone:817-424-3668
Mailing Address - Fax:817-442-8637
Practice Address - Street 1:1940 HWY 114 SUITE 150
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-424-3668
Practice Address - Fax:817-442-8637
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2019-07-17
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
GAPOD000998213E00000X
GA000998213ES0103X
TX2397213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582964905AMedicaid
GAP00427172OtherRAILROAD MEDICARE PTAN
0202370001Medicare NSC
GAP00427172OtherRAILROAD MEDICARE PTAN
GA48SCCSNMedicare PIN