Provider Demographics
NPI:1982792578
Name:JIMENEZ, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:JIMENEZ
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 1:321 E ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2667
Mailing Address - Country:US
Mailing Address - Phone:619-934-3260
Mailing Address - Fax:619-934-3268
Practice Address - Street 1:321 E ST STE A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2667
Practice Address - Country:US
Practice Address - Phone:619-934-3260
Practice Address - Fax:619-934-3268
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46465207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G464650Medicaid
CA00G464650Medicaid
CAA92647Medicare UPIN