Healthcare Provider Details

I. General information

NPI: 1922219336
Provider Name (Legal Business Name): EDWARD ALEXANDER JIMENEZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OLD COUNTRY RD SUITE 365
MINEOLA NY
11501-4235
US

IV. Provider business mailing address

200 OLD COUNTRY RD SUITE 365
MINEOLA NY
11501-4235
US

V. Phone/Fax

Practice location:
  • Phone: 516-294-5440
  • Fax: 516-294-1206
Mailing address:
  • Phone: 516-294-5440
  • Fax: 516-294-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number255535
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: