Basic Information
| Provider Information | |||||||||
| NPI: | 1235846791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | URB FLAMINGO HLS | ||||||||
| Address2: | 28 CALLE MAIN | ||||||||
| City: | BAYAMON | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009571721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877874706 | ||||||||
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| Practice Location | |||||||||
| Address1: | GOB. PINERO, PASEO DR. JOSE CELSO BARBOSA | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874740333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.