Healthcare Provider Details

I. General information

NPI: 1013910751
Provider Name (Legal Business Name): RODOLFO JIMENEZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2005
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 S CAMPBELL RD
GREEN VALLEY AZ
85614
US

IV. Provider business mailing address

1260 S CAMPBELL AVE BLDG. 2
GREEN VALLEY AZ
85614-0503
US

V. Phone/Fax

Practice location:
  • Phone: 520-625-3691
  • Fax: 520-625-2894
Mailing address:
  • Phone: 520-407-5606
  • Fax: 520-625-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2763
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: