Healthcare Provider Details

I. General information

NPI: 1164085932
Provider Name (Legal Business Name): EDWIN JIMENEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COULTER RD STE 1680
CLIFTON SPRINGS NY
14432-1122
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 315-462-2636
  • Fax: 315-359-2675
Mailing address:
  • Phone:
  • Fax: 585-922-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number326173
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: