Healthcare Provider Details

I. General information

NPI: 1356551931
Provider Name (Legal Business Name): DR. MAIRAMANDY JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIF. MEDICO SANTA CRUZ #73 SUITE 316
BAYAMON PR
00961
US

IV. Provider business mailing address

PO BOX 9162
BAYAMON PR
00960-9162
US

V. Phone/Fax

Practice location:
  • Phone: 787-787-3268
  • Fax:
Mailing address:
  • Phone: 787-787-3268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number14119
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14119
License Number StatePR

VII. Legacy identifiers

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

# 1
Identifier14119
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerGENERALIST

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: