Healthcare Provider Details

I. General information

NPI: 1063430767
Provider Name (Legal Business Name): MIGUEL A JIMENEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W HART RD
BELOIT WI
53511
US

IV. Provider business mailing address

2101 RIVERSIDE DR
BELOIT WI
53511
US

V. Phone/Fax

Practice location:
  • Phone: 608-364-5269
  • Fax:
Mailing address:
  • Phone: 608-362-7888
  • Fax: 608-362-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26724020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: