Healthcare Provider Details

I. General information

NPI: 1376533034
Provider Name (Legal Business Name): JOHN JIMENEZ-AGOSTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 CALLE SANTA CRUZ FOURTH FLOOR
BAYAMON PR
00961-6900
US

IV. Provider business mailing address

C/ LIMONCILLO #73 SANTA MARIA
SAN JUAN PR
00927-6622
US

V. Phone/Fax

Practice location:
  • Phone: 787-717-6240
  • Fax:
Mailing address:
  • Phone: 787-717-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5724
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: