=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912941774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITZI T JIMENEZ M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 05/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 S WAYSIDE DR STE 150
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77023-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-923-6333
-----------------------------------------------------
Fax | 713-923-4197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 231233
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77223-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-923-6333
-----------------------------------------------------
Fax | 713-923-4197
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | F6790
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------