Healthcare Provider Details

I. General information

NPI: 1841794302
Provider Name (Legal Business Name): CHRISTOPHER RYAN JIMENEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 TOWN PARK BLVD
EVANS GA
30809-3487
US

IV. Provider business mailing address

PO BOX 1758
EVANS GA
30809-1758
US

V. Phone/Fax

Practice location:
  • Phone: 706-854-2500
  • Fax: 706-854-2559
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number87917
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier003252094A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: