Healthcare Provider Details

I. General information

NPI: 1649705567
Provider Name (Legal Business Name): JIMMIE MAR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 09/05/2022
Certification Date: 09/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 TECHNOLOGY DR
SAN JOSE CA
95110-1305
US

IV. Provider business mailing address

1721 TECHNOLOGY DR
SAN JOSE CA
95110-1305
US

V. Phone/Fax

Practice location:
  • Phone: 408-436-3300
  • Fax:
Mailing address:
  • Phone: 408-436-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number305596
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A20119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: