Healthcare Provider Details

I. General information

NPI: 1083827067
Provider Name (Legal Business Name): EDGARDO E JIMENEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

B13 CALLE TREVI
SAN JUAN PR
00926-6478
US

IV. Provider business mailing address

PO BOX 360549
SAN JUAN PR
00936-0549
US

V. Phone/Fax

Practice location:
  • Phone: 787-653-3434
  • Fax:
Mailing address:
  • Phone: 787-748-2465
  • Fax: 787-760-1750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number05567
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: