Healthcare Provider Details

I. General information

NPI: 1457352890
Provider Name (Legal Business Name): RICKY JIMENEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 CALLE WASHINGTON ASHFORD MEDICAL CENTER SUITE 202
SAN JUAN PR
00907-1510
US

IV. Provider business mailing address

1047 CALLE CARITE URB. VALLES DEL LAGO
CAGUAS PR
00725-7645
US

V. Phone/Fax

Practice location:
  • Phone: 787-977-5011
  • Fax: 787-977-5062
Mailing address:
  • Phone: 787-747-0246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12272
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: