Basic Information
| Provider Information | |||||||||
| NPI: | 1598236440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ IRAHETA | ||||||||
| FirstName: | OSCAR | ||||||||
| MiddleName: | ALFREDO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S DOUGLAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448541116 | ||||||||
| FaxNumber: | 3058469711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S DOUGLAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448541116 | ||||||||
| FaxNumber: | 3058469711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | BACB454134 | FL | N | 103K00000X | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 103590500 | 05 | FL | MEDICAID |