Healthcare Provider Details

I. General information

NPI: 1376245126
Provider Name (Legal Business Name): IANCARLOS JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF PUERTO RICO MEDICAL SCIENCES CAMPUS
SAN JUAN PR
00926
US

IV. Provider business mailing address

UNIVERSITY OF PUERTO RICO MEDICAL SCIENCES CAMPUS
SAN JUAN PR
00926-5067
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-2525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number38246
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: