Healthcare Provider Details

I. General information

NPI: 1851443725
Provider Name (Legal Business Name): CARLOS ALBERTO JIMENEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 05/06/2023
Certification Date: 05/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 MAITLAND AVE STE 104
ALTAMONTE SPRINGS FL
32701-4913
US

IV. Provider business mailing address

2201 NORTH BLVD W
DAVENPORT FL
33837-8990
US

V. Phone/Fax

Practice location:
  • Phone: 407-557-2165
  • Fax:
Mailing address:
  • Phone: 863-419-0688
  • Fax: 863-419-9547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA9100035
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: